NICE antenatal care guideline

Antenatal care for uncomplicated pregnancies

Woman‑centred care and informed decision‑making

• The principles outlined in this section apply to all aspects of the antenatal care guideline

Antenatal information

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 vitaminD deficiency, and details of the Healthy Start programme
  • exercise, including pelvic floor exercises
  • place of birth (refer to intrapartum care NICE guideline CG55)
  • pregnancy care pathway
  • breastfeeding, including workshops
  • participant‑led antenatal classes
  • further discussion of all antenatal screening
  • discussion of mental health issues (refer to antenatal and postnatal mental health NICE guideline CG45)
• Before or at 36weeks:
  • breastfeeding information, including technique and good management practices that would help a woman succeed, such as detailed in the UNICEF Baby Friendly Initiative
  • 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 38weeks:
  • options for management of prolonged pregnancy
• 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
• Information can also be given in other forms such as audiovisual or touch‑screen technology; this should be supported by written 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
• 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
• Pregnant women should be offered opportunities to attend participant‑led antenatal classes, including breastfeeding workshops
• Women's decisions should be respected, even when this is contrary to the views of the healthcare professional
• 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
• 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
• 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 GP‑led models of care should be offered to 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 pregnant 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 seven 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 minimise inconvenience to women

Gestational age assessment

• Pregnant women should be offered an early ultrasound scan between 10weeks0 days and 13weeks6 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
• Crown–rump length measurement should be used to determine gestational age. If the crown–rump length is above 84mm, 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
• A woman's occupation during pregnancy should be ascertained to identify those who are 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 throughout the first 12weeks, reduces the risk of having a baby with a neural tube defect (for example, anencephaly or spina bifida). The recommended dose is 400micrograms 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 vitaminA supplementation (intake above 700micrograms) might be teratogenic and should therefore be avoided. Pregnant women should be informed that liver and liver products may also contain high levels of vitaminA, and therefore consumption of these products should also be avoided
• 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 should be advised to take a vitamin D supplement (10micrograms of vitamin D per day), as found in the Healthy Start multivitamin supplement. Women who are not eligible for the Healthy Start benefit should be advised where they can buy the 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 with darker skin (such as those of African, African–Caribbean or South Asian family origin
  • women who have limited exposure to sunlight, such as women who are housebound or confined indoors for long periods, or who cover their skin for cultural reasons (see also NICE's guideline on vitamin D: increasing supplement use among at-risk groups)

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
• 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

• 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
• 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 (1unit equals half a pint of ordinary strength lager or beer, or one shot [25ml] of spirits. One small [125ml] glass of wine is equal to 1.5UK 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
• Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5standard drinks or 5UK units on a single occasion) may be harmful to the unborn baby

Smoking in pregnancy

• 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
• 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
• Offer personalised information, advice and support on how to stop smoking. Encourage pregnant women to use local 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
• Monitor smoking status and offer smoking cessation advice, encouragement and support throughout the pregnancy and beyond
• 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
• Advise women using nicotine patches to remove them before going to bed

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 seatbelts (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 20weeks 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 it 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 are 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 booking appointment, and the woman's body mass index should be calculated (weight [kg]/height[m]2)
• Repeated weighing during pregnancy should be confined to circumstances in which 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

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 28weeks when other blood screening tests are being performed. This allows enough time for treatment if anaemia is detected
• Haemoglobin levels outside the normal UK range for pregnancy (that is, 11g/100ml at first contact and 10.5g/100ml at 28weeks) should be investigated and iron supplementation considered if indicated

Blood grouping and red‑cell alloantibodies

• Women should be offered testing for blood group and rhesusD status in early pregnancy
• It is recommended that routine antenatal anti‑D prophylaxis is offered to all non‑sensitised pregnant women who are rhesusD‑negative
• Women should be screened for atypical red‑cell alloantibodies in early pregnancy and again at 28weeks, regardless of their rhesusD 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 rhesusD‑negative, consideration should be given to offering partner testing to determine whether the administration of anti‑D prophylaxis is necessary

Screening for haemoglobinopathies

• 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
• 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
• Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10weeks). The type of screening depends upon the prevalence and can be carried out in either primary or secondary care
• Where prevalence of sickle cell disease is high (fetal prevalence above 5cases 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
• Where prevalence of sickle cell disease is low (fetal prevalence 5cases 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 27picograms, laboratory screening (preferably high‑performance liquid chromatography) should be offered
• 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