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Antenatal care:routine care for the
healthy pregnant woman
NICE Clinical Guideline October 2003
Summary of recommendations and practice algorithm
3.2 Antenatal Education
Pregnant women should be offered opportunities to attend
antenatal classes and have written information about antenatal
care. [A]
Pregnant women should be offered evidence-based information
and support to enable them to make informed decisions regarding
their care. Information should include details of where they
will be seen and who will undertake their care. Addressing
women’s choices should be recognised as being integral to the
decision-making process. [C]
At the first contact, pregnant women should be offered
information about the pregnancy care services and options
available, lifestyle considerations, including dietary
information, and screening tests. [C]
Pregnant women should be informed about the purpose of any
screening test before it is performed. The right of a woman to
accept or decline a test should be made clear. [D]
At each antenatal appointment, midwives and doctors should
offer consistent information and clear explanations and should
provide pregnant women with an opportunity to discuss issues and
ask questions. [D]
Communication and information should be provided in a form
that is accessible to pregnant women who have additional needs,
such as those with physical, cognitive or sensory disabilities
and those who do not speak or read English. [Good practice
point]
4.1 Who provides care?
Midwife- and 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. [A]
4.2 Continuity of care
Antenatal care should be provided by a small group of carers
with whom the woman feels comfortable. There should be
continuity of care throughout the antenatal period. [A]
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. [D]
4.3 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. [C]
4.4 Documentation of care
Structured maternity records should be used for antenatal
care. [A]
Maternity services should have a system in place whereby
women carry their own case notes. [A]
A standardised, national maternity record with an agreed
minimum data set should be developed and used. This will help
carers to provide the recommended evidence-based care to
pregnant women. [Good practice point]
4.5 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 ten appointments should be adequate.
For a woman who is parous with an uncomplicated pregnancy, a
schedule of seven appointments should be adequate. [B]
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. [D]
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 minimise inconvenience to women. [D]
4.6 Gestational age assessment: LMP and ultrasound
Pregnant women should be offered an early ultrasound scan to
determine gestational age (in lieu of last menstrual period
(LMP) for all cases) and to detect multiple pregnancies. This
will ensure consistency of gestational age assessments, improve
the performance of mid-trimester serum screening for Down’s
syndrome and reduce the need for induction of labour after 41
weeks. [A] Ideally, scans should be performed between 10 and 13
weeks and use crown–rump length measurement to determine
gestational age.
Pregnant women who present at or beyond 14 weeks of gestation
should be offered an ultrasound scan to estimate gestational age
using head circumference or biparietal diameter. [Good practice
point]
4.7 What should happen at antenatal appointments?
First appointment
The first appointment needs to be earlier in pregnancy (prior
to 12 weeks) than may have traditionally occurred and, because
of the large volume of information needs in early pregnancy, two
appointments may be required. At the first (and second)
antenatal appointment:
• give information, with an opportunity to discuss issues and
ask questions; offer verbal information supported by written
information (on topics such as diet and lifestyle
considerations, pregnancy care services available, maternity
benefits and sufficient information to enable informed decision
making about screening tests)
• identify women who may need additional care and plan
pattern of care for the pregnancy
• check blood group and rhesus D (RhD) status
• offer screening for anaemia, red-cell alloantibodies,
Hepatitis B virus, HIV, rubella susceptibility and syphilis
• offer screening for asymptomatic bacteriuria (ASB)
• offering screening for Down’s syndrome • offer early
ultrasound scan for gestational age assessment
• offer ultrasound screening for structural anomalies (20
weeks)
• measure BMI and blood pressure (BP) and test urine for
proteinuria .
After the first (and possibly second) appointment, for women
who choose to have screening, the following test should be
arranged before 16 weeks of gestation (except serum screening
for Down’s syndrome, which may occur up to 20 weeks of
gestation):
• blood tests (for checking blood group and RhD status and
screening for anaemia, red-cell alloantibodies, hepatitis B
virus, HIV, rubella susceptibility and syphilis)
• urine tests (to check for proteinuria and screen for ASB)
• ultrasound scan to determine gestational age using:
• crown–rump measurement if performed at 10 to 13 weeks
• biparietal diameter or head circumference at or beyond 14
weeks
• Down’s syndrome screening using:
• nuchal translucency at 11 to 14 weeks
• serum screening at 14 to 20 weeks.
16 weeks
The next appointment should be scheduled at 16 weeks to:
• review, discuss and record the results of all screening
tests undertaken; reassess planned pattern of care for the
pregnancy and identify women who need additional care
• investigate a haemoglobin level of less than 11g/dl and
consider iron supplementation if indicated
• measure BP and test urine for proteinuria
• give information, with an opportunity to discuss issues and
ask questions; offer verbal information supported by antenatal
classes and written information.
18–20 weeks
At 18–20 weeks, if the woman chooses, an ultrasound scan
should be performed for the detection of structural anomalies.
For a woman whose placenta is found to extend across the
internal cervical os at this time, another scan at 36 weeks
should be offered and the results of this scan reviewed at the
36-week appointment.
25 weeks
At 25 weeks of gestation, another appointment should be
scheduled for nulliparous women.
At this appointment:
• measure and plot symphysis–fundal height
• measure BP and test urine for proteinuria
• give information, with an opportunity to discuss issues and
ask questions; offer verbal information supported by antenatal
classes and written information.
28 weeks
The next appointment for all pregnant women should occur at
28 weeks.
At this appointment:
• offer a second screening for anaemia and atypical red-cell
alloantibodies
• investigate a haemoglobin level of less than 10.5 g/dl and
consider iron supplementation, if indicated
• offer anti-D to rhesus-negative women
• measure BP and test urine for proteinuria
• measure and plot symphysis–fundal height
• give information, with an opportunity to discuss issues and
ask questions; offer verbal information supported by antenatal
classes and written information.
31 weeks
Nulliparous women should have an appointment scheduled at 31
weeks to:
• measure BP and test urine for proteinuria
• measure and plot symphysis–fundal height
• review, discuss and record the results of screening tests
undertaken at 28 weeks; reassess planned pattern of care for the
pregnancy and identify women who need additional care
5.6 Food-acquired infections
Pregnant women should be offered information on how to reduce
the risk of listeriosis by:
• drinking only pasteurised or 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.
[D] 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.
[D]
5.7 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
where the benefit outweighs the risk. [D]
5.8 Over-the-counter medicines
Pregnant women should be informed that few over-the-counter
(OTC) medicines have been established as being safe to take in
pregnancy. OTC medicines should be used as little as possible
during pregnancy. [D]
5.9 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. [D]
5.10 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. [A] 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. [D]
5.11 Sexual intercourse in pregnancy
Pregnant woman should be informed that sexual intercourse in
pregnancy is not known to be associated with any adverse
outcomes. [B]
5.12 Alcohol and smoking in pregnancy
Excess alcohol has an adverse effect on the fetus. Therefore
it is suggested that women limit alcohol consumption to no more
than one standard unit per day. Each of the following
constitutes one ‘unit’ of alcohol: a single measure of spirits,
one small glass of wine, and a half pint of ordinary strength
beer, lager or cider. [C]
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). The benefits of quitting at any
stage should be emphasised. [A]
Women who smoke or who have recently stopped should be
offered smoking cessation interventions. Interventions that
appear to be effective in reducing smoking include advice by
physician, group sessions and behavioural therapy (based on
self-help manuals). [A] Women who are unable to quit smoking
during pregnancy should be encouraged to reduce smoking. [B]
5.13 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. [C]
5.14 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. [B]
5.15 Car travel during pregnancy
Pregnant women should be informed about the correct use of
seatbelts (that is, three-point seatbelts “above and below the
bump, not over it”). [B]
5.16 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. [Good practice point]
Management of common symptoms of pregnancy
6.1 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 [A]:
• nonpharmacological:
• ginger
• P6 acupressure
• pharmacological:
• antihistamines.
Information about all forms of self-help and
nonpharmacological treatments should be made available for
pregnant women who have nausea and vomiting. [Good practice
point]
6.2 Heartburn
Women who present with symptoms of heartburn in pregnancy
should be offered information regarding lifestyle and diet
modification. [Good practice point] Antacids may be offered to
women whose heartburn remains troublesome despite lifestyle and
diet modification. [A]
6.3 Constipation
Women who present with constipation in pregnancy should be
offered information regarding diet modification, such as bran or
wheat fibre supplementation. [A]
6.4 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. [Good practice point]
6.5 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. [A]
6.6 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 maybe an infective cause
and investigation should be considered. [Good practice point] A
1-week course of a topical imidazole is an effective treatment
and should be considered for vaginal candidiasis infections in
pregnant women. [A] The effectiveness and safety of oral
treatments for vaginal candidiasis in pregnancy is uncertain and
these should not be offered. [Good practice point]
6.7 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. [A]
Clinical examination of pregnant women
7.1 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 (BMI)
calculated (weight [kg]/height[m]2). [B]
Repeated weighing during pregnancy should be confined to
circumstances where clinical management is likely to be
influenced. [C]
7.2 Breast examination
Routine breast examination during antenatal care is not
recommended for the promotion of postnatal breastfeeding. [A]
7.3 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. [B]
7.4 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. [C]
7.5 Domestic violence
Health care 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. [D]
7.6 Psychiatric screening
Women should be asked early in pregnancy if they have had any
previous psychiatric illnesses. Women who have had a past
history of serious psychiatric disorder should be referred for a
psychiatric assessment during the antenatal period. [B]
Pregnant women should not be offered routine screening, such
as with the Edinburgh Postnatal Depression Scale, in the
antenatal period to predict the development of postnatal
depression. [A]
Pregnant women should not be offered antenatal education
interventions to reduce perinatal or postnatal depression, as
these interventions have not been shown to be effective. [A]
Screening for haematological conditions
8.1 Anaemia
Pregnant women should be offered screening for anaemia.
Screening should take place early in pregnancy (at the first
appointment) and at 28 weeks when other blood screening tests
are being performed. This allows enough time for treatment if
anaemia is detected. [B]
Haemoglobin levels outside the normal UK range for pregnancy
(that is, 11 g/dl at first contact and 10.5 g/dl at 28 weeks)
should be investigated and iron supplementation considered if
indicated. [A]
8.3 Blood grouping and red cell alloantibodies
Women should be offered testing for blood group and RhD
status in early pregnancy. [B]
It is recommended that routine antenatal anti-D prophylaxis
is offered to all non-sensitised pregnant women who are RhD
negative. [NICE 2002] Women should be screened for atypical red
cell alloantibodies in early pregnancy and again at 28 weeks
regardless of their RhD status. [B]
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.[D]
If a pregnant woman is RhD-negative, consideration should be
given to offering partner testing to determine whether the
administration of anti-D prophylaxis is necessary. [Good
practice point]
Screening for fetal anomalies
9.1 Screening for structural anomalies
Pregnant women should be offered an ultrasound scan to screen
for structural anomalies, ideally between 18 and 20 weeks of
gestation, by an appropriately trained sonographer and with
equipment of an appropriate standard [A]
9.2 Screening for Down’s syndrome Pregnant women should be
offered screening for Down’s syndrome with a test that provides
the current standard of a detection rate above 60% and a false
positive rate of less than 5%.
The following tests meet this standard:
• From 11 to 14 weeks:
• nuchal translucency (NT)
• the combined test (NT, hCG and PAPP-A)
• From 14 to 20 weeks:
• the triple test (hCG, AFP and uE3)
• the quadruple test (hCG, AFP, uE3, inhibin A)
• From 11 to 14 weeks AND 14 to 20 weeks:
• the integrated test (NT, PAPP-A + hCG, AFP, uE3, inhibin A)
• the serum integrated test (PAPP-A + hCG, AFP, uE3, inhibin
A). [B]
Pregnant women should be offered screening for Down’s
syndrome with a test which provides a detection rate above 75%
and a false positive rate of less than 3%. These performance
measures should be age standardised and based on a cutoff of
1/250 at term. The following tests currently meet this standard:
• From 11 to 14 weeks:
• the combined test (NT, hCG and PAPP-A)
• From 14 to 20 weeks:
• the quadruple test (hCG, AFP, uE3, inhibin A)
• From 11 to 14 weeks AND 14 to 20 weeks:
• the integrated test (NT, PAPP-A + hCG, AFP, uE3, inhibin A)
• the serum integrated test (PAPP-A + hCG, AFP, uE3, inhibin
A). [B]
Pregnant women should be given information about the
detection rates and false positive rates of any Down’s syndrome
screening test being offered and about further diagnostic tests
that may be offered. The woman’s right to accept or decline the
test should be made clear. [D]
Screening for infections
10.1 Asymptomatic bacteriuria
Pregnant 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 preterm birth. [A]
10.2 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. [A]
10.3 Chlamydia trachomatis
Pregnant women should not be offered routine screening for
asymptomatic chlamydia because there is insufficient evidence on
its effectiveness and cost effectiveness. However, this policy
is likely to change with the implementation of the national
opportunistic chlamydia screening programme. [C]
10.4 Cytomegalovirus
The available evidence does not support routine
cytomegalovirus screening in pregnant women and it should not be
offered. [B]
10.5 Hepatitis B virus
Serological screening for hepatitis B virus 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. [A]
10.6 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. [C]
10.7 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]
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. [D]
10.8 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. [B]
10.9 Streptococcus
Group B 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. [C]
10.10 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 fetus. [B]
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. [Good practice
point]
10.11 Toxoplasmosis
Routine antenatal serological screening for toxoplasmosis
should not be offered because the harms of screening may
outweigh the potential benefits. [B] 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. [C]
Screening for clinical conditions
11.1 Gestational diabetes mellitus
The evidence does not support routine screening for
gestational diabetes mellitus (GDM) and therefore it should not
be offered. [B]
11.2 Pre-eclampsia
At first contact a woman’s level of risk for pre-eclampsia
should be evaluated so that a plan for her subsequent schedule
of antenatal appointments can be formulated. The likelihood of
developing pre-eclampsia during a pregnancy is increased in
women who:
• are nulliparous
• are age 40 or older
• have a family history of pre-eclampsia (e.g., pre-eclampsia
in a mother or sister)
• have a prior history of pre-eclampsia
• have a body mass index (BMI) at or above 35 at first
contact
• have a multiple pregnancy or pre-existing vascular disease
(for example, hypertension or diabetes). [C]
Whenever blood pressure is measured in pregnancy, a urine
sample should be tested at the same time for proteinuria. [C]
Standardised equipment, techniques and conditions for
blood-pressure measurement should be used by all personnel
whenever blood pressure is measured in the antenatal period so
that valid comparisons can be made. [C]
Pregnant women should be informed of the symptoms of advanced
pre-eclampsia because these may be associated with poorer
pregnancy outcomes for the mother or baby. Symptoms include
headache, problems with vision, such as blurring or flashing
before the eyes, bad pain just below the ribs, vomiting and
sudden swelling of face, hands or feet. [D]
11.3 Preterm birth
Routine vaginal examination to assess the cervix is not an
effective method of predicting preterm birth and should not be
offered. [A]
Although cervical shortening identified by transvaginal
ultrasound examination and increased levels of fetal fibronectin
are associated with an increased risk for preterm birth, the
evidence does not indicate that this information improves
outcomes; therefore, neither routine antenatal cervical
assessment by transvaginal ultrasound nor the measurement of
fetal fibronectin should be used to predict preterm birth in
healthy pregnant women. [B]
11.4 Placenta praevia
Because most low-lying placentas detected at a 20-week
anomaly scan will resolve 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 36 weeks. If
the transabdominal scan is unclear, a transvaginal scan should
be offered. [C]
Fetal growth and wellbeing
12.1 Abdominal palpation for fetal presentation
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. [C]
Suspected fetal malpresentation should be confirmed by an
ultrasound assessment. [Good practice point]
12.2 Measurem ent of symphysis–fundal distance
Pregnant women should be offered estimation of fetal size at
each antenatal appointment to detect small- or
large-for-gestational-age infants. [A] Symphysis–fundal height
should be measured and plotted at each antenatal appointment.
[Good practice point]
12.3 Routine monitoring of fetal movements
Routine formal fetal-movement counting should not be offered.
[A]
12.4 Auscultation of fetal heart
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. [D]
12.5 Cardiotocography
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. [A]
12.6 Ultrasound assessment in the third trimester
The evidence does not support the routine use of ultrasound
scanning after 24 weeks of gestation and therefore it should not
be offered. [A]
12.7 Umbilical and uterine artery Doppler ultrasound
The use of umbilical artery Doppler ultrasound for the
prediction of fetal growth restriction should not be offered
routinely. [A]
The use of uterine artery Doppler ultrasound for the
prediction of pre-eclampsia should not be offered routinely. [B]
Management of specific clinical conditions
13.1 Pregnancy after 41 weeks
Prior to formal induction of labour, women should be offered
a vaginal examination for membrane sweeping. [A]
Women with uncomplicated pregnancies should be offered
induction of labour beyond 41 weeks. [A]
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. [Good practice point]
13.2 Breech presentation at term
All women who have an uncomplicated singleton breech
pregnancy at 36 weeks of gestation should be offered external
cephalic version (ECV). Exceptions include women in labour and
women with a uterine scar or abnormality, fetal compromise,
ruptured membranes, vaginal bleeding and medical conditions. [A]
Where it is not possible to schedule an appointment for ECV
at 37 weeks of gestation, it should be scheduled at 36 weeks.
[Good practice point]  |
