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Guideline Summary
Guideline Title
Antenatal care. Routine care for the healthy pregnant woman.
Bibliographic Source(s)
National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the healthy pregnant woman. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Mar. 56 p. (Clinical guideline; no. 62). 
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the healthy pregnant woman. London: RCOG Press; 2003 Oct. 286 p. [631 references]

The National Collaborating Centre for Women's and Children's Health reaffirmed the currency of this guideline in 2011.

Scope

Disease/Condition(s)

Pregnancy

Note: Although the guideline addresses screening for many of the complications of pregnancy, it does not include information on the investigation and appropriate ongoing management of these complications if they arise in pregnancy (for example, the management of preeclampsia, fetal anomalies, and multiple pregnancies).

Any aspect of intrapartum and postpartum care has not been included in this guideline. This includes preparation for birth and parenthood, risk factor assessment for intrapartum care, breastfeeding, and postnatal depression. These topics will be addressed in future National Institute for Clinical Excellence (NICE) guidelines on intrapartum and postpartum care. In addition, preconception care is not covered in this guideline.

The guideline offers recommendations on baseline clinical care for all pregnant women, but it does not offer information on the additional care that some women will require. Pregnant women with certain conditions usually require care additional to that detailed in this guideline. Refer to section 1.2 of the full version of the guideline or Appendix C of the short version for a list of these conditions.

Guideline Category
Counseling
Evaluation
Management
Risk Assessment
Screening
Treatment
Clinical Specialty
Anesthesiology
Family Practice
Internal Medicine
Obstetrics and Gynecology
Pediatrics
Preventive Medicine
Radiology
Intended Users
Advanced Practice Nurses
Health Care Providers
Health Plans
Managed Care Organizations
Nurses
Patients
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Guideline Objective(s)
  • To offer information on best practice for baseline clinical care of all pregnancies and comprehensive information on the antenatal care of the healthy woman with an uncomplicated singleton pregnancy
  • To provide evidence-based information for clinicians and pregnant women to make decisions about appropriate treatment in specific circumstances
  • To complement the Children's National Service framework, which provides standards for service configuration, with emphasis on how care is delivered and by whom, including issues of ensuring equity of access to care for disadvantaged women and women's views about service provision
Target Population

Pregnant women in England and Wales with uncomplicated singleton pregnancy

Interventions and Practices Considered

Counseling

  1. Type and timing of antenatal information for all pregnant women
  2. Appropriate form of and setting for giving of information
  3. Antenatal classes
  4. Cultural and individual sensitivity
  5. Lifestyle considerations (working, nutritional supplements, infection prevention, use of medications, exercise, sexual intercourse, alcohol, tobacco or cannabis smoking, travel)

Evaluation/Screening

  1. Clinical examination of the pregnant woman
    • Measurement of weight and body mass index
    • Breast examination (not recommended routinely)
    • Pelvic examination (not recommended)
    • Assessment of female genital mutilation
    • Assessment for domestic violence
  2. Prediction, detection and initial management of mental disorders
  3. Assessment of fetal growth and well-being
  4. Screening for haematologic conditions
  5. Screening for structural fetal anomalies or Down's syndrome
  6. Screening for infections
    • Recommended: asymptomatic bacteruria, hepatitis B virus, HIV, rubella, syphilis
    • Not recommended routinely: bacterial vaginosis, cytomegalovirus, group B streptococcus, hepatitis C virus, toxoplasmosis
    • Referral for testing recommended as appropriate: Chlamydia trachomatis
  7. Screening for clinical conditions
    • Gestational diabetes in the presence of risk factors (screening using fasting plasma glucose, random blood glucose, glucose challenge test, and urinalysis not recommended)
    • Pre-eclampsia
    • Preterm birth (not recommended)
  8. Assessment of placenta previa, if appropriate

Management

  1. Provision and organization of care
  2. Gestational age assessment
  3. Management of common symptoms (nausea and vomiting, heartburn, constipation, haemorrhoids, varicose veins, vaginal discharge, backache)
  4. Management of pregnancy after 41 weeks
  5. Management of breech presentation at birth
Major Outcomes Considered
  • Fetal growth and well-being
  • Incidence of preterm birth
  • Incidence of fetal anomalies
  • Mother-to-child infection transmission rate
  • Perinatal mortality
  • Infant outcomes
  • Interventions during labour
  • Birth weight
  • Complications of delivery
  • Sensitivity and specificity for diagnostic tests
  • Maternal satisfaction
  • Quality adjusted life years
  • Cost

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

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.

Literature Search Strategy (2003 Guideline)

The aim of the literature review was to identify and synthesise relevant evidence within the published literature, in order to answer the specific clinical questions. Searches were performed using generic and specially developed filters, relevant MeSH (medical subject headings) terms and free-text terms. Details of all literature searches are available upon application to the NCC-WCH.

Guidelines by other development groups were searched for on the National Guidelines Clearinghouse database, the TRIP database and OMNI service on the Internet. The reference lists in these guidelines were checked against the searches to identify any missing evidence. Searches were carried out for each topic of interest. The Cochrane Database of Systematic Reviews, up to Issue 3, 2003, was searched to identify systematic reviews of randomised controlled trials, with or without meta-analyses and randomised controlled trials. The electronic database, MEDLINE (Ovid version for the period January 1966 to April 2003), EMBASE (Ovid version from January 1980 to April 2003), MIDIRS (Midwives Information and Resource Service), CINAHL (Cumulative Index to Nursing and Allied Health Literature), the British Nursing Index (BNI) and PsychInfo were also searched.

The Database of Abstracts and Reviews of Effectiveness (DARE) was searched. Reference lists of nonsystematic review articles and studies obtained from the initial search were reviewed and journals in the Royal College of Obstetricians and Gynaecologists (RCOG) library were hand-searched to identify articles not yet indexed. There was no systematic attempt to search the 'grey literature' (conferences, abstracts, theses and unpublished trials).

A preliminary scrutiny of titles and abstracts was undertaken and full papers were obtained if they appeared to address the Guideline Development Group (GDG)'s question relevant to the topic. Following a critical review of the full version of the study, articles not relevant to the subject in question were excluded. Studies that did not report on relevant outcomes were also excluded. Submitted evidence from stakeholders was included where the evidence was relevant to the GDG clinical question and when it was either better or equivalent in quality to the research identified in the literature searches.

The economic evaluation included a search of:

  • National Health Service (NHS) Economic Evaluations Database (NHS EED)
  • Health Economic Evaluation Database (HEED)
  • Cochrane Database of Systematic Reviews, Issue 3, 2003
  • MEDLINE January 1966 to April 2003
  • EMBASE 1980 to April 2003

Relevant experts in the field were contacted for further information.

The search strategies were designed to find any economic study related to specific antenatal screening programmes. Abstracts and database reviews of papers found were reviewed by the health economist and were discarded if they appeared not to contain any economic data or if the focus of the paper did not relate to the precise topic or question being considered (i.e., to screening strategy alternatives that were not relevant to this guideline). Relevant references in the bibliographies of reviewed papers were also identified and reviewed. These were assessed by the health economists against standard criteria.

Literature Search Strategy for the 2008 Update

Relevant published evidence to inform the guideline development process and answer the clinical questions was identified by systematic search strategies. Additionally, stakeholder organisations were invited to submit evidence for consideration by the GDG provided it was relevant to the clinical questions and of equivalent or better quality than evidence identified by the search strategies.

Systematic searches to answer the clinical questions formulated and agreed by the GDG were executed using the following databases via the 'Ovid' platform: Medline (1966 onwards), Embase (1980 onwards), Cumulative Index to Nursing and Allied Health Literature (1982 onwards) and PsycINFO (1967 onwards). The most recent search conducted for the three Cochrane databases (Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects) was during Quarter 1, 2007. Searches to identify economic studies were undertaken using the above databases, and the NHS Economic Evaluations Database (NHS EED).

Search strategies combined relevant controlled vocabulary and natural language in an effort to balance sensitivity and specificity. Unless advised by the GDG, searches were not date specific. Language restrictions were not applied to searches. Both generic and specially developed methodological search filters were used appropriately.

There was no systematic attempt to search grey literature (conferences, abstracts, theses and unpublished trials). Hand searching of journals not indexed on the databases was not undertaken.

Towards the end of the guideline development process searches were re-executed, thereby including evidence published and included in the databases up to 8 June 2007. Any evidence published after this date was not included. This date should be considered the starting point for searching for new evidence for future updates to this guideline.

Further details of the search strategies, including the methodological filters employed, are available (see the "Availability of Companion Documents" field).

Currency Review

The National Collaborating Centre for Women's and Children's Health undertook a review of this guideline in 2011 and determined that the information is current. See the NICE Web site External Web Site Policy for the review decision.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Structure of Evidence Levels (2003 Guideline)

Level Definition
1a Systematic review and meta-analysis of randomised controlled trials
1b At least one randomized controlled trial
2a At least one well-designed controlled study without randomization
2b At least one other type of well-designed quasi-experimental study
3 Well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, or case studies
4 Expert committee reports or opinions and/or clinical experience of respected authorities

Levels of Evidence for Studies of the Accuracy of Diagnostic Tests (2008 Update)

Level Type of Evidence
Ia Systematic review (with homogeneity)a of level-1 studiesb
Ib Level-1 studiesb
II Level-2 studiesc; systematic reviews of level-2 studies
III Level-3 studiesd; systematic reviews of level-3 studies
IV Consensus, expert committee reports or opinions and/or clinical experience without explicit critical appraisal; or based on physiology, bench research or 'first principles'

a Homogeneity means there are no or minor variations in the directions and degrees of results between individual studies that are included in the systematic review.

b Level-1 studies are studies that use a blind comparison of the test with a validated reference standard (gold standard) in a sample of patients that reflects the population to whom the test would apply.

c Level-2 studies are studies that have only one of the following:

  • Narrow population (the sample does not reflect the population to whom the test would apply)
  • Use a poor reference standard (defined as that where the 'test' is included in the 'reference', or where the 'testing' affects the 'reference')
  • The comparison between the test and reference standard is not blind
  • Case–control studies

d Level-3 studies are studies that have at least two or three of the features listed above

Levels of Evidence for Intervention Studies (2008 Update)

Level Source of Evidence
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies; high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies (for example, case reports, case series)
4 Expert opinion, formal consensus
Methods Used to Analyze the Evidence
Meta-Analysis
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

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.

Clinical Effectiveness (2003 Guideline)

For all the subject areas, evidence from the study designs least subject to sources of bias was included. Where possible, the highest levels of evidence were used, but all papers were reviewed using established guides (see below and "Rating Scheme for the Strength of the Evidence" field). Published systematic reviews or meta-analyses were used if available. For subject areas where neither was available, other appropriate experimental or observational studies were sought.

Identified articles were assessed methodologically and the best available evidence was used to form and support the recommendations. The highest level of evidence was selected for each clinical question. Using the evidence-level structure (see the "Rating Scheme for the Strength of the Evidence" field), the retrieved evidence was graded accordingly was graded accordingly.

Hierarchy of Evidence (2003 Guideline)

The clinical question dictates the highest level of evidence that should be sought. For issues of therapy or treatment, the highest level of evidence is meta-analyses of randomised controlled trials or randomised controlled trials themselves. This would equate to a grade A recommendation.

For issues of prognosis, a cohort study is the best level of evidence available. The best possible level of evidence would equate to a grade B recommendation. It should not be interpreted as an inferior grade of recommendation, as it represents the highest level of evidence attainable for that type of clinical question.

For diagnostic tests, test evaluation studies examining the performance of the test were used if the efficacy of the test was required. Where an evaluation of the effectiveness of the test on management and outcome was required, evidence from randomised controlled trials or cohort studies was sought.

All retrieved articles have been appraised methodologically using established guides. Where appropriate, if a systematic review, meta-analysis or randomised controlled trial existed in relation to a topic, studies of a weaker design were not sought.

The evidence was synthesised using qualitative methods. These involved summarising the content of identified papers in the form of evidence tables and agreeing brief statements that accurately reflect the relevant evidence. Quantitative techniques (meta-analyses) were performed if appropriate and necessary.

For the purposes of this guideline, data are presented as relative risk (RR) where relevant (i.e., in randomised controlled trials [RCTs] and cohort studies) or as odds ratios (OR) where relevant (i.e., in systematic reviews of RCTs). Where these data are statistically significant they are also presented as numbers needed to treat (NNT), if relevant.

Appraisal and Synthesis of Clinical Effectiveness Evidence for the 2008 Update

Evidence relating to clinical effectiveness was reviewed and classified using the established hierarchical system presented in the Levels of Evidence for Intervention Studies (see the "Rating Scheme for the Strength of the Evidence" field). This system reflects the susceptibility to bias that is inherent in particular study designs.

The type of clinical question dictates the highest level of evidence that may be sought. In assessing the quality of the evidence, each study was assigned a quality rating coded as '++', '+' or '−'. For issues of therapy or treatment, the highest possible evidence level (EL) is a well-conducted systematic review or meta-analysis of randomised controlled trials (RCTs; EL = 1++) or an individual RCT (EL = 1+). Studies of poor quality were rated as '−'. Usually, studies rated as '−' should not be used as a basis for making a recommendation, but they can be used to inform recommendations. For issues of prognosis, the highest possible level of evidence is a cohort study (EL = 2). A level of evidence was assigned to each study appraised during the development of the guideline.

For each clinical question, the highest available level of evidence was selected. Where appropriate, for example, if a systematic review, meta-analysis or RCT existed in relation to a question, studies of a weaker design were not considered. Where systematic reviews, meta-analyses and RCTs did not exist, other appropriate experimental or observational studies were sought. For diagnostic tests, test evaluation studies examining the performance of the test were used if the effectiveness (accuracy) of the test was required, but where an evaluation of the effectiveness of the test in the clinical management of patients and the outcome of disease was required, evidence from RCTs or cohort studies was optimal. For studies evaluating the accuracy of a diagnostic test, sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs) were calculated or quoted where possible (see Table 1.4 in the full version of the original guideline document).

The system described above covers studies of treatment effectiveness. However, it is less appropriate for studies reporting accuracy of diagnostic tests. In the absence of a validated ranking system for this type of test, NICE has developed a hierarchy of evidence that takes into account the various factors likely to affect the validity of these studies (see "Rating Scheme for the Strength of the Evidence" field).

Methods Used to Formulate the Recommendations
Expert Consensus (Delphi)
Expert Consensus (Nominal Group Technique)
Informal Consensus
Description of Methods Used to Formulate the Recommendations

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.

The Guideline was developed by a multi-professional and lay working group, the Guideline Development Group (GDG), convened by NCC-WCH. Membership in the 2008 update GDG* included:

  • Two service user representatives
  • Two midwives
  • Two obstetricians
  • A general practitioner
  • An ultrasonographer
  • A Medical Research Council (MRC)-funded public health research fellow

Staff from NCC-WCH provided methodological support for the guideline development process, undertook the systematic searches, retrieval, and appraisal of the evidence, and wrote successive drafts of the document.

*Note: For the 2003 guideline, membership included two service user representatives, two general practitioners, two midwives, two obstetricians, a radiographer, a neonatologist, and a representative from the Confidential Enquiry into Maternal Deaths (CEMD).

Guideline Methodology

The development of the guideline was commissioned by NICE and developed in accordance with the guideline development process outlined in The Guideline Development Process – Information for National Collaborating Centres and Guideline Development Groups, available from the NICE website (www.nice.org.uk External Web Site Policy).

Update Methodology

The guideline update was developed in accordance with the NICE guideline development process outlined in the 2006 and 2007 editions of the guidelines manual. Table 1.1 in the full version of the original guideline document summarises the key stages of the guideline development process and which version of the process was followed at each stage.

Forming and Grading the Recommendations (2003 Guideline)

The GDG was presented with the summaries (text and evidence tables) of the best available research evidence to answer their questions. Recommendations were based on, and explicitly linked to, the evidence that supported them. A recommendation's grade may not necessarily reflect the importance attached to the recommendation. For example, the GDG felt that the principles of woman-centred care that underpin this guideline (see Chapter 3 in the full version of the original guideline document) are particularly important but some of these recommendations receive only a D grade or good practice point (GPP).

The GDG worked where possible on an informal consensus basis. Formal consensus methods (modified Delphi techniques or nominal group technique) were employed if required (e.g., grading recommendations or agreeing audit criteria).

The recommendations were then graded according to the level of evidence upon which they were based. The strength of the evidence on which each recommendation is based is shown in the table below in the section "Rating Scheme for the Strength of the Recommendations". The grading of recommendations will follow that outlined in the Health Technology Assessment (HTA) review How to develop cost conscious guidelines.

Forming and Grading the Recommendations for the 2008 Update

The updated NICE guideline methodology manual (2007) requires that recommendations are no longer graded. The 2008 recommendations in this update therefore do not have a grade; however, the grade assigned to 2003 recommendations has been left in place. The Antenatal Assessment Tool was developed using formal consensus methodology (see Chapter 14 in the full version of the original guideline document for further details).

Rating Scheme for the Strength of the Recommendations

Strength of the Evidence Upon Which Each Recommendation Is Based (2003 guideline recommendations only)

Grade Definition
A Directly based on level I evidence
B Directly based on level II evidence or extrapolated recommendation from level I evidence
C Directly based on level III evidence or extrapolated recommendation from either level I or II evidence
D Directly based on level IV evidence or extrapolated recommendation from either level I, II or III evidence
Good practice point (GPP) The view of the Guideline Development Group
NICE Technology Appraisal Recommendation taken from a NICE Technology Appraisal
Cost Analysis

Health Economics

In antenatal care, there is a relatively large body of economic literature that has considered the economic costs and consequences of different screening programmes and considered the organisation of antenatal care. The purpose of including economic evidence in a clinical guideline is to allow recommendations to be made not just on the clinical effectiveness of different forms of care, but on the cost effectiveness as well. The aim is to produce guidance that uses scarce health service resources efficiently; that is, providing the best possible care within resource constraints.

The economic evidence is focused around the different methods of screening, although some work has been undertaken to examine the cost effectiveness of different patterns of antenatal care (the number of antenatal appointments) and to explore women's preferences for different aspects of their antenatal care. The economic evidence presented in this guideline is not a systematic review of all the economic evidence around antenatal care. It was decided that the health economic input into the guideline should focus on specific topics where the guideline development group (GDG) thought that economic evidence would help them to inform their decisions. This approach was made on pragmatic grounds (not all the economic evidence could be reviewed with the resources available) and on the basis that economic evidence should not be based only on the economic literature, but should be consistent with the clinical effectiveness evidence presented in the guideline. Some of the economic evaluation studies did not address the specific alternatives (say, for screening) that were addressed in the guideline. Therefore, for each of the specific topic areas where the economic evidence was reviewed, a simple economic model was developed in order to present the GDG with a coherent picture of the costs and consequences of the decisions based on the clinical and economic evidence. The role of the health economist in this guideline was to review the literature in these specific areas and obtain cost data considered to be the closest to current UK opportunity cost (the value of the resources used, rather than the price or charge).

The approach adopted for this guideline was for the health economic analysis to focus on specific areas. Topics for economic analysis were selected on the following basis by the GDG.

  • Does the proposed topic have major resource implications?
  • Is there a change of policy involved?
  • Are there sufficient data of adequate quality to allow useful review or modelling?
  • Is there a lack of consensus among clinicians?
  • Is there a particular area with a large amount of uncertainty?

Where the above answers were "yes," this indicated that further economic analysis including modelling is more likely to be useful.

The GDG identified six areas where the potential impact of alternative strategies could be substantial and where the health economics evidence should focus. These were: screening for asymptomatic bacteriuria, screening for group B streptococcus, screening for syphilis, screening for sickle cell and thalassaemia, ultrasound screening for structural abnormalities, and Down's syndrome screening.

For all these topics, a review of the economic evidence was undertaken, followed by simple economic modelling of the cost-effectiveness in England and Wales of different strategies.

The review of the economic evaluation studies included cost-effectiveness studies (only those where an incremental cost-effectiveness ratio [ICER] had been determined or could be determined from the data presented). The topic had to focus on the appropriate alternatives (the appropriate clinical question), preferably able to be generalised to the England and Wales setting, and therefore be useful in constructing a simple decision model. The review of the evidence included cost-effectiveness studies, cost-consequence studies (cost of present and future costs only), and high-quality systematic reviews of the evidence. A narrative review of all the evidence is not presented in the main guideline. Appendices B to F of the full version of the original guideline document show the way the models have been constructed, the economic and clinical parameters incorporated into each model, the sources of data that have been used (cost data and clinical data), the results of the baseline model, and the sensitivity analysis.

Evidence on the cost consequences associated with alternative screening strategies was obtained from various published sources that addressed these issues. The purpose was to obtain good quality cost data judged by the health economist to be as close as possible to the true opportunity cost of the intervention (screening programme).

The key cost variables considered were:

  • The cost of a screening programme (the cost of different screening interventions and the cost of expanding and contracting a screening programme)
  • The cost of treatment of women found to be carriers of a disease
  • The cost of any adverse or non-therapeutic effects of screening or treatment to the woman
  • The cost of the consequences of screening and not screening to the fetus and infant, including fetal loss, ending pregnancy, and the lifetime costs of caring for infants born with disabilities

Cost data not available from published sources were obtained from the most up-to-date National Health Service (NHS) reference cost price list. Some cost data could not be obtained from published sources or from NHS reference costs and in such cases, an indicative estimate of the likely costs was obtained from the GDG. The range of sources of cost data are set out in the appendix that explains the methodology adopted to construct each of the economic models created for this guideline.

In some cases (i.e., for screening for group B streptococcus and syphilis), the economic modelling work could not be completed owing to lack of clinical evidence relating to the different screening options. Appendices C and D of the full version of the original guideline document provide some discussion of these models that could not be completed in the guideline and areas for future research.

Limitations of the Economic Evidence in this Guideline

Economic analyses have been undertaken alongside a wide range of antenatal screening procedures. A systematic review of antenatal screening was undertaken in 2001. This review found that many of the studies identified were of poor quality, since they did not consider the effects of screening on future health (of mother and baby) but only costs averted by a screening programme.

In this guideline, the costs of screening and the costs of the benefits or harm of screening have been considered simultaneously where possible (i.e., where the data exist). It has not been possible to include many of the consequences of a screening programme because the data do not exist on these less straightforward or measurable outcomes (such as the benefit foregone from ending pregnancy).

The economic analysis of screening methods in the guideline has not been able to consider the following:

  • The value to the woman of being given information about the health of her future child
  • The value of being able to plan appropriate services for children who are born with disabilities
  • The value of a life of a child born with disability, to the child, to the family, and to society in general
  • The value to a woman of being able to choose whether to end a pregnancy
  • The value of a life foregone as a consequence of screening

The cost-effectiveness studies reviewed for this guideline had narrowly defined endpoints; for example, a case of birth defect detected and subsequently averted as a result of a screening test. Some of the studies have considered the cost consequences of avoiding the birth of an infant with severe disabilities and their long-term care costs. The value of future life foregone (of a healthy or a disabled infant's life) due to screening has not been explicitly considered in any of the economic evidence of antenatal screening. Since economic evaluation should always consider the costs and benefits of an intervention in the widest possible sense, this could be seen as a limitation of the analysis presented in this guideline. The consequences of this are discussed in Appendices B to G in the full version of the original guideline document as appropriate.

Health Economics for the 2008 Update

The aim of the economic input into the guideline was to inform the GDG of potential economic issues relating to antenatal care. The health economist helped the GDG by identifying topics within the guideline that might benefit from economic analysis, reviewing the available economic evidence and, where necessary, conducting (or commissioning) economic analysis. Reviews of published health economic evidence are presented alongside the reviews of clinical evidence and are incorporated within the relevant evidence statement and recommendations. For some questions, no published evidence was identified, and decision analytic modelling was undertaken. Results of this modelling are presented in the guideline text where appropriate, with full details in Appendices B to G inclusive in the full version of the original guideline document.

Economic evaluations in this guideline have been conducted in the form of a cost-effectiveness analysis, with the health effects measured in an appropriate non-monetary outcome indicator. The NICE technology appraisal programme measures outcomes in terms of quality-adjusted life years (QALYs). Where possible, this approach has been used in the development of this guideline. However, where it has not been possible to estimate QALYs gained as a result of an intervention, an alternative measure of effectiveness has been used.

Cost-effectiveness analysis, with the units of effectiveness expressed in QALYs (known as cost–utility analysis) is widely recognised as a useful approach for measuring and comparing the efficiency of different health interventions. The QALY is a measure of health outcome which assigns to each period of time (generally 1 year) a weight, ranging from 0 to 1, corresponding to health-related quality of life during that period. It is one of the most commonly used outcome measures in health economics. A score of 1 corresponds to full health and a score of 0 corresponds to a health state equivalent to death. Negative valuations, implying a health state worse than death, are possible. Health outcomes using this method are measured by the number of years of life in a given health state multiplied by the value of being in that health state.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline has been developed in accordance with the National Institute for Clinical Excellence (NICE) guideline development process. This has included the opportunity for registered stakeholders to comment on the scope of the guideline, the first draft of the full and summary guidelines, and the second draft of all versions of the guideline. In addition, the first draft was reviewed by nominated individuals with an interest in antenatal care. All drafts, comments, and responses were also reviewed by the independent Guideline Review Panel established by NICE.

The comments made by the stakeholders, peer reviewers, and the NICE Guideline Review Panel were collated and presented anonymously for consideration by the Guideline Development Group (GDG). All comments were considered systematically by the Group and the resulting actions and responses were recorded.

Recommendations

Major Recommendations

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.

Antenatal Information

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 External Web Site Policy)
  • Exercise, including pelvic floor exercises
  • Place of birth (refer to 'Intrapartum care' [NICE clinical guideline 55], available from http://guidance.nice.org.uk/CG55 External Web Site Policy)
  • 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 External Web Site Policy).

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 External Web Site Policy)
  • 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 External Web Site Policy)

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 External Web Site Policy).

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.

Lifestyle Considerations

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 External Web Site Policy).

A woman's occupation during pregnancy should be ascertained to identify those at increased risk through occupational exposure.

Nutritional Supplements

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

Food-Acquired Infections

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

Prescribed Medicines

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.

Over-the-Counter Medicines

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.

Complementary Therapies

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 External Web Site Policy). 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:

  • Non-pharmacological
    • Ginger
    • P6 (wrist) acupressure
  • Pharmacological
    • Antihistamines

Information about all forms of self-help and non-pharmacological treatments should be made available for pregnant women who have nausea and vomiting.

Heartburn

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.

Constipation

Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation.

Haemorrhoids

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.

Varicose Veins

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.

Vaginal Discharge

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.

Backache

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.

Breast Examination

Routine breast examination during antenatal care is not recommended for the promotion of postnatal breastfeeding.

Pelvic Examination

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.

Domestic Violence

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 External Web Site Policy). 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

Anaemia

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 External Web Site Policy).

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

Asymptomatic Bacteriuria

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.

Chlamydia trachomatis

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 External Web Site Policy).

New. Chlamydia screening should not be offered as part of routine antenatal care.

Cytomegalovirus

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.

HIV

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

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.

Syphilis

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.

Toxoplasmosis

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

Gestational Diabetes

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 External Web Site Policy)
  • 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 External Web Site Policy).

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.

Pre-eclampsia

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
  • Nulliparity
  • 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
  • Vomiting
  • 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.

Preterm Birth

New. Routine screening for preterm labour should not be offered.

Placenta Praevia

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 External Web Site Policy.)

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.

Clinical Algorithm(s)

A clinical algorithm is provided for the routine care for the healthy pregnant woman.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • The provision of appropriate, cost-effective care to healthy women with uncomplicated singleton pregnancies
  • Early detection and referral for treatment of complications of pregnancy, with improved pregnancy outcomes
Potential Harms

Not stated

Contraindications

Contraindications

 

  • Live vaccines are generally contraindicated during pregnancy because of largely theoretical risks to the fetus. Measles, mumps, rubella, bacillus-Calmette-Guérin (BCG) and yellow fever vaccines should be avoided in pregnancy.
  • Doxycycline is contraindicated during pregnancy.
  • Proguanil hydrochloride with atovaquone should be avoided during pregnancy unless there is no suitable alternative.

 

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer and informed by the summary of product characteristics of any drugs they are considering.
  • The guideline will not produce standards for service configuration, which are being addressed by the Children's National Service Frameworks (England and Wales), nor will it address quality standard issues (such as laboratory standards), which are addressed by the National Screening Committee.

Implementation of the Guideline

Description of Implementation Strategy

Implementation

The Healthcare Commission assesses the performance of National Health Service (NHS) organisations in meeting core and developmental standards set by the Department of Health in 'Standards for better health'. Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that national agreed guidance should be taken into account when NHS organisations are planning and delivering care.

The National Institute for Health and Clinical Excellence (NICE) has developed tools to help organisations implement this guidance (listed below). These are available on the NICE website (http://guidance.nice.org.uk/CG62 External Web Site Policy).

  • Slides highlighting key messages for local discussion
  • Costing tools:
    • Costing report to estimate the national savings and costs associated with implementation
    • Costing template to estimate the local costs and savings involved
  • Implementation advice on how to put the guidance into practice and national initiatives which support this locally
  • Audit support for monitoring local practice

Key Priorities for Implementation

Antenatal Information

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.

Lifestyle Considerations

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

Screening for Haematological Conditions

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.

Screening for Fetal Anomalies

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.

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.

Screening for Clinical Conditions

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 External Web Site Policy)
  • 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], available from http://guidance.nice.org.uk/CG63 External Web Site Policy).

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the healthy pregnant woman. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Mar. 56 p. (Clinical guideline; no. 62). 
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 Oct (revised 2008 Mar; reaffirmed 2011)
Guideline Developer(s)
National Collaborating Centre for Women's and Children's Health - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Group Members: Rhona Hughes (Chair), Consultant Obstetrician, Simpson Centre for Reproductive Health, Edinburgh; Eva Aitken, Work Programme Coordinator, National Collaborating Centre for Women's and Children's Health; Jane Anderson, Specialist Ultrasonographer, Princess Anne Hospital, Southampton; Chris Barry, General Practitioner, Swindon; Marie Benton, Service User Representative, Communications Manager – Down's Syndrome Association; Jennifer Elliott, Service User Representative, National Childbirth Trust; Rupert Franklin, Work Programme Coordinator, National Collaborating Centre for Women's and Children's Health; Paul Jacklin, Senior Health Economist, National Collaborating Centre for Women's and Children's Health; Rajesh Khanna, Research Fellow, National Collaborating Centre for Women's and Children's Health; Nina Khazaezadeh, Consultant Midwife and Supervisor of Midwives, St Thomas' Hospital, London; Rachel Knowles, Medical Research Council-funded Research Fellow in Public Health, University College London Institute of Child Health; Rintaro Mori, Research Fellow, National Collaborating Centre for Women's and Children's Health; Francesco Moscone, Health Economist, National Collaborating Centre for Women's and Children's Health; Tim Overton, Consultant Obstetrician, St Michael's Hospital, Bristol; Debbie Pledge, Senior Information Scientist, National Collaborating Centre for Women's and Children's Health; Jeff Round, Health Economist, National Collaborating Centre for Women's and Children's Health; Anuradha Sekhri, Research Fellow, National Collaborating Centre for Women's and Children's Health; Roz Ullman, Senior Research Fellow, National Collaborating Centre for Women's and Children's Health; Martin Whittle, Clinical Co-Director for Women's Health, National Collaborating Centre for Women's and Children's Health; Katie Yiannouzis, Head of Midwifery, King's College Hospital, London

Financial Disclosures/Conflicts of Interest

At each Guideline Development Group (GDG) meeting, all GDG members declared any potential conflict of interests. See Appendix A of the full version of the guideline document for a list of declarations.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the healthy pregnant woman. London: RCOG Press; 2003 Oct. 286 p. [631 references]

The National Collaborating Centre for Women's and Children's Health reaffirmed the currency of this guideline in 2011.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Antenatal care. Routine care for the healthy pregnant woman. Full guideline. London (UK): National Institute for Health and Care Excellence (NICE); 2008 Mar. 454 p. (Clinical guideline; no. 62). Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Care Excellence (NICE) Web site External Web Site Policy.
  • Antenatal care. Routine care for the healthy pregnant woman. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence; 2008 Mar. 28 p. (Clinical guideline; no. 62). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Antenatal care. Diabetes in pregnancy. Costing report. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2008 Mar. 51 p. (Clinical guideline; no. 62 and 63). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Antenatal care. Diabetes in pregnancy. Costing template. London (UK): National Institute for Health and Clinical Excellence; 2008 Mar. Various p. (Clinical guideline; no. 62). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Antenatal care. Audit support. London (UK): National Institute for Health and Clinical Excellence; 2008. 11 p. (Clinical guideline; no. 62). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Antenatal care. Slide set. London (UK): National Institute for Health and Clinical Excellence; 2008. 13 p. (Clinical guideline; no. 62). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • The guidelines manual 2007. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 April. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.

Additional accompanying guideline materials can be found from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Patient Resources

The following is available:

  • Routine antenatal care for healthy pregnant women. Understanding NICE guidance -  Information for people who use NHS services. London (UK): National Institute for Health and Clinical Excellence; 2008 Mar. 23 p. (Clinical guideline; no. 62). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on August 27, 2004. This summary was updated by ECRI Institute on September 30, 2009. The currency of the guideline was reaffirmed by the developer in 2011 and this summary was updated by ECRI Institute on October 30, 2013.

Copyright Statement

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

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