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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]
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