Ensure that antenatal care can be started in a variety of straightforward ways, depending on women's needs and circumstances, for example, by self-referral, referral by a GP, midwife or another healthcare professional, or through a school nurse, community centre or refugee hostel.
1.1.2At the point of antenatal care referral:
Provide an easy-to-complete referral form.
Offer early pregnancy health and wellbeing information before the booking appointment. This should include information about modifiable factors that may affect the pregnancy, including stopping smoking, avoiding alcohol, taking supplements, and eating healthily. See also recommendation 1.3.9 and the NICE guidelines on maternal and child nutrition, vitamin D, and tobacco: preventing uptake, promoting quitting and treating dependence.
Ensure that the materials are available in different languages or formats such as digital, printed, braille or Easy Read.
The referral form for women to start antenatal care should:
enable healthcare professionals to identify women with:
specific health and social care needs
risk factors, including those that can potentially be addressed before the booking appointment, for example, smoking
include contact details about the woman's GP.
Offer a first antenatal (booking) appointment with a midwife to take place by 10+0 weeks of pregnancy.
1.1.5If women contact or are referred to maternity services later than 9+0 weeks of pregnancy, offer a first antenatal (booking) appointment to take place within 2 weeks if possible.
1.1.6If a woman books late in pregnancy, ask about the reasons for the late booking because it may reveal social, psychological or medical issues that need to be addressed.
1.1.7Plan 10 routine antenatal appointments with a midwife or doctor for nulliparous women. (See schedule of appointments.)
1.1.8Plan 7 routine antenatal appointments with a midwife or doctor for parous women. (See schedule of appointments.)
1.1.9Also see the NICE guideline on pregnancy and complex social factors for:
women who misuse substances
recent migrants, asylum seekers or refugees, or women who have difficulty reading or speaking English
young women aged under 20
women who experience domestic abuse.
Offer additional or longer antenatal appointments if needed, depending on the woman's medical, social and emotional needs. Also see the NICE guidelines on pregnancy and complex social factors, intrapartum care for women with existing medical conditions or obstetric complications and their babies, hypertension in pregnancy, diabetes in pregnancy and twin and triplet pregnancy.
1.1.11Ensure that reliable interpreting services are available when needed, including British Sign Language. Interpreters should be independent of the woman rather than using a family member or friend.
1.1.12Those responsible for planning and delivering antenatal services should aim to provide continuity of carer.
1.1.13Ensure that there is effective and prompt communication between healthcare professionals who are involved in the woman's care during pregnancy.
Involving partners 1.1.14A woman can be supported by a partner during her pregnancy so healthcare professionals should:
involve partners according to the woman's wishes and
inform the woman that she is welcome to bring a partner to antenatal appointments and classes.
Consider arranging the timing of antenatal classes so that the pregnant woman's partner can attend, if the woman wishes.
1.1.16When planning and delivering antenatal services, ensure that the environment is welcoming for partners as well as pregnant women by, for example:
providing information about how partners can be involved in supporting the woman during and after pregnancy
providing information about pregnancy for partners as well as pregnant women
displaying positive images of partner involvement (for example, on notice boards and in waiting areas)
providing seating in consultation rooms for both the woman and her partner
considering providing opportunities for partners to attend appointments remotely as appropriate.
At the first antenatal (booking) appointment, ask the woman about:
her medical history, obstetric history and family history (of both biological parents)
previous or current mental health concerns such as depression, anxiety, severe mental illness, psychological trauma or psychiatric treatment, to identify possible mental health problems in line with the section on recognising mental health problems in pregnancy and the postnatal period and referral in the NICE guideline on antenatal and postnatal mental health
current and recent medicines, including over-the-counter medicines, health supplements and herbal remedies
allergies
her occupation, discussing any risks and concerns
her family and home situation, available support network and any health or other issues affecting her partner or family members that may be significant for her health and wellbeing
other people who may be involved in the care of the baby
contact details for her partner and her next of kin
factors such as nutrition and diet, physical activity, smoking and tobacco use, alcohol consumption and recreational drug use (see also recommendations 1.3.8 and 1.3.9).
Consider reviewing the woman's previous medical records if needed, including records held by other healthcare providers.
1.2.3Be aware that, according to the 2020 MBRRACE-UK reports on maternal and perinatal mortality, women and babies from some minority ethnic backgrounds and those who live in deprived areas have an increased risk of death and may need closer monitoring and additional support. The reports showed that:
compared with white women (8/100,000), the risk of maternal death during pregnancy and up to 6 weeks after birth is:
4 times higher in black women (34/100,000)
3 times higher in women with mixed ethnic background (25/100,000)
2 times higher in Asian women (15/100,000; does not include Chinese women)
compared with white babies (34/10,000), the stillbirth rate is
more than twice as high in black babies (74/10,000)
around 50% higher in Asian babies (53/10,000)
women living in the most deprived areas (15/100,000) are more than 2.5 times more likely to die compared with women living in the least deprived areas (6/100,000)
the stillbirth rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many stillbirths for women living in the most deprived areas (47/10,000) compared with the least deprived areas (26/10,000).
If the woman or her partner smokes or has stopped smoking within the past 2 weeks, offer a referral to NHS Stop Smoking Services in line with the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence.
1.2.5Ask the woman about domestic abuse in a kind, sensitive manner at the first antenatal (booking) appointment, or at the earliest opportunity when she is alone. Ensure that there is an opportunity to have a private, one‑to‑one discussion. Also see the NICE guideline on domestic violence and abuse and the section on pregnant women who experience domestic abuse in the NICE guideline on pregnancy and complex social factors.
1.2.6Assess the woman's risk of and, if appropriate, discuss female genital mutilation (FGM) in a kind, sensitive manner. Take appropriate action in line with UK government guidance on safeguarding women and girls at risk of FGM.
1.2.7Refer the woman for a clinical assessment by a doctor to detect cardiac conditions if there is a concern based on the pregnant woman's personal or family history. See also the section on heart disease in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.
1.2.8Refer the woman to an obstetrician or other relevant doctor if there are any medical concerns or if review of current long-term medicines is needed.
1.2.9After discussion with and agreement from the woman, contact the woman's GP to share information about the pregnancy and potential concerns or complications during pregnancy.
1.2.10At every antenatal appointment, carry out a risk assessment as follows:
ask the woman about her general health and wellbeing
ask the woman (and her partner, if present) if there are any concerns they would like to discuss
provide a safe environment and opportunities for the woman to discuss topics such as concerns at home, domestic abuse, concerns about the birth (for example, if she previously had a traumatic birth) or mental health concerns
review and reassess the plan of care for the pregnancy
identify women who need additional care.
For guidance on organising, planning and providing care and support for pregnant women who are approaching end of life and their carers, see the NICE guideline on end of life care for adults: service delivery.
At every antenatal contact, update the woman's antenatal records to include details of history, test results, examination findings, medicines and discussions.
Examinations and investigations 1.2.12At the first face-to-face antenatal appointment:
offer to measure the woman's height and weight and calculate body mass index
offer a blood test to check full blood count, blood group and rhesus D status.
At the first antenatal (booking) appointment, discuss and share information about, and then offer, the following screening programmes:
NHS infectious diseases in pregnancy screening programme (HIV, syphilis and hepatitis B)
NHS fetal anomaly screening programme.
Inform the woman that she can accept or decline any part of any of the screening programmes offered.
Offer pregnant women an ultrasound scan to take place between 11+2 weeks and 14+1 weeks to:
determine gestational age
detect multiple pregnancy
and if opted for, screen for Down's syndrome, Edwards' syndrome and Patau's syndrome (see the NHS fetal anomaly screening programme).
Offer pregnant women an ultrasound scan to take place between 18+0 weeks and 20+6 weeks to:
screen for fetal anomalies (see the NHS fetal anomaly screening programme)
determine placental location.
At the antenatal appointment at 28 weeks, offer:
a blood test to check full blood count, blood group and antibodies
anti-D prophylaxis to rhesus D-negative women who are not known to be sensitised to the rhesus D antigen in line with NICE's technology appraisal guidance on routine antenatal anti-D prophylaxis (TA156, 2008), also see NICE's diagnostics guidance on high-throughput non-invasive prenatal testing for fetal RHD genotype.
If there are any unexpected results from examinations or investigations, offer referral according to local pathways and ensure appropriate information provision and support.
Monitoring fetal growth and wellbeing 1.2.29Offer a risk assessment for fetal growth restriction at the first antenatal (booking) appointment, and again in the second trimester. Consider using guidance by an appropriate professional or national body, for example, the Royal College of Obstetricians and Gynaecologists' guideline on the investigation and management of the small-for-gestational-age fetus or the NHS saving babies' lives care bundle version 2.
1.2.30Offer symphysis fundal height measurement at each antenatal appointment after 24+0 weeks (but no more frequently than every 2 weeks) for women with a singleton pregnancy unless the woman is having regular growth scans. Plot the measurement onto a growth chart in line with the NHS saving babies' lives care bundle version 2.
1.2.31If there are concerns that the symphysis fundal height is large for gestational age, consider an ultrasound scan for fetal growth and wellbeing.
1.2.32If there are concerns that the symphysis fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
1.2.33Do not routinely offer ultrasound scans after 28 weeks for uncomplicated singleton pregnancies.
1.2.34Discuss the topic of babies' movements with the woman after 24+0 weeks, and:
ask if she has any concerns about her baby's movements at each antenatal contact after 24+0 weeks
advise her to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements after 24+0 weeks
assess the woman and baby if there are any concerns about the baby's movements.
Service providers should recognise that the use of structured fetal movement awareness packages, such as the one studied in the AFFIRM trial, has not been shown to reduce stillbirth rates.
1.3 Information and support for pregnant women and their partners Communication – key principles 1.3.1When caring for a pregnant woman, listen to her and be responsive to her needs and preferences. Also see the NICE guideline on patient experience in adult NHS services, in particular the sections on communication and information, and the NICE guideline on shared decision making.
1.3.2Ensure that when offering any assessment, intervention or procedure, the risks, benefits and implications are discussed with the woman and she is aware that she has a right to decline.
1.3.3Women's decisions should be respected, even when this is contrary to the views of the healthcare professional.
1.3.4When giving women (and their partners) information about antenatal care, use clear language, and tailor the timing, content and delivery of information to the needs and preferences of the woman and her stage of pregnancy. Information should support shared decision making between the woman and her healthcare team, and be:
offered on a one-to-one or couple basis
supplemented by group discussions (women only or women and partners)
supplemented by written information in a suitable format, for example, digital, printed, braille or Easy Read
offered throughout the woman's care
individualised and sensitive
supportive and respectful
evidence-based and consistent
translated into other languages if needed.
For more guidance on communication, providing information (including different formats and languages), and shared decision making, see the NICE guideline on patient experience in adult NHS services and the NHS Accessible Information Standard.
Explore the knowledge and understanding that the woman (and her partner) has about each topic to individualise the discussion.
1.3.6Check that the woman (and her partner) understands the information that has been given, and how it relates to them. Provide regular opportunities to ask questions, and set aside enough time to discuss any concerns.
Information about antenatal care 1.3.7At the first antenatal (booking) appointment, discuss antenatal care with the woman (and her partner) and provide her schedule of antenatal appointments.
1.3.8At the first antenatal (booking) appointment (and later if appropriate), discuss and give information on:
what antenatal care involves and why it is important
the planned number of antenatal appointments
where antenatal appointments will take place
which healthcare professionals will be involved in antenatal appointments
how to contact the midwifery team for non-urgent advice
how to contact the maternity service about urgent concerns, such as pain and bleeding
screening programmes: what blood tests and ultrasound scans are offered and why
how the baby develops during pregnancy
what to expect at each stage of the pregnancy
physical and emotional changes during the pregnancy
mental health during the pregnancy
relationship changes during the pregnancy
how the woman and her partner can support each other
immunisation for flu, pertussis (whooping cough) and other infections (for example, COVID‑19) during pregnancy, in line with the NICE guideline on flu vaccination and the Public Health England Green Book on immunisation against infectious disease
infections that can impact on the baby in pregnancy or during birth (such as group B streptococcus, herpes simplex and cytomegalovirus)
reducing the risk of infections, for example, encouraging hand washing
safe use of medicines, health supplements and herbal remedies during pregnancy
resources and support for expectant and new parents
how to get in touch with local or national peer support services.
At the first antenatal (booking) appointment, and later if appropriate, discuss and give information about nutrition and diet, physical activity, smoking cessation and recreational drug use in a non-judgemental, compassionate and personalised way. See the NICE guidelines on maternal and child nutrition, vitamin D, tobacco: preventing uptake, promoting quitting and treating dependence, and the section on pregnant women who misuse substances (alcohol and/or drugs) in the NICE guideline on pregnancy and complex social factors.
1.3.10At the first antenatal (booking) appointment, and later if appropriate, discuss alcohol consumption and follow the UK Chief Medical Officers' low-risk drinking guidelines. Explain that:
there is no known safe level of alcohol consumption during pregnancy
drinking alcohol during the pregnancy can lead to long-term harm to the baby
the safest approach is to avoid alcohol altogether to minimise risks to the baby.
Throughout the pregnancy, discuss and give information on:
physical and emotional changes during the pregnancy
relationship changes during the pregnancy
how the woman and her partner can support each other
resources and support for expectant and new parents
how the parents can bond with their baby and the importance of emotional attachment (also see the section on promoting emotional attachment in the NICE guideline on postnatal care)
the results of any blood or screening tests from previous appointments.
After 24 weeks, discuss babies' movements (see also recommendation 1.2.34).
1.3.14Before 28 weeks, start talking with the woman about her birth preferences and the implications, benefits and risks of different options (see the section on planning place of birth in the NICE guideline on intrapartum care and the section on planning mode of birth in the NICE guideline on caesarean birth).
1.3.15After 28 weeks, discuss and give information on:
preparing for labour and birth, including information about coping in labour and creating a birth plan
recognising active labour
the postnatal period, including:
care of the new baby
the baby's feeding
vitamin K prophylaxis
newborn screening
postnatal self-care, including pelvic floor exercises
awareness of mood changes and postnatal mental health.
Also see the NICE guideline on postnatal care.
From 28 weeks onwards, as appropriate, continue the discussions and confirm the woman's birth preferences, discussing the implications, benefits and risks of all the options.
1.3.17From 38 weeks, discuss prolonged pregnancy and options on how to manage this, in line with the NICE guideline on inducing labour.
1.3.18See the NICE guideline on preterm labour and birth for women at increased risk of, or with symptoms and signs of, preterm labour (before 37 weeks), and women having a planned preterm birth.
1.3.19Provide appropriate information and support for women whose baby is considered to be at an increased risk of neonatal admission.
Peer support 1.3.23Discuss the potential benefits of peer support with pregnant women (and their partners), and explain how it may:
provide practical support
help to build confidence
reduce feelings of isolation.
Offer pregnant women (and their partners) information about how to access local and national peer support services.
Sleep position 1.3.25Advise women to avoid going to sleep on their back after 28 weeks of pregnancy and to consider using pillows, for example, to maintain their position while sleeping.
1.3.26Explain to the woman that there may be a link between going to sleep on her back and stillbirth in late pregnancy (after 28 weeks).
1.4 Interventions for common problems during pregnancy Symptomatic vaginal discharge 1.4.10Advise pregnant women who have vaginal discharge that this is common during pregnancy, but if it is accompanied by symptoms such as itching, soreness, an unpleasant smell or pain on passing urine, there may be an infection that needs to be investigated and treated.
1.4.11Consider carrying out a vaginal swab for pregnant women with symptomatic vaginal discharge if there is doubt about the cause.
1.4.12If a sexually transmitted infection is suspected, consider arranging appropriate investigations.
1.4.13Offer vaginal imidazole (such as clotrimazole or econazole) to treat vaginal candidiasis in pregnant women.
1.4.14Consider oral or vaginal antibiotics to treat bacterial vaginosis in pregnant women in line with the NICE guideline on antimicrobial stewardship.
Pelvic girdle pain 1.4.15For women with pregnancy-related pelvic girdle pain, consider referral to physiotherapy services for:
exercise advice and/or
a non-rigid lumbopelvic belt.
Offer anti-D immunoglobulin to women who present with vaginal bleeding after 13 weeks of pregnancy if they are:
rhesus D-negative and
at risk of isoimmunisation.
Refer pregnant women with unexplained vaginal bleeding after 13 weeks to secondary care for a review.
1.4.18For pregnant women with unexplained vaginal bleeding after 13 weeks, assess whether to admit them to hospital, taking into account:
the risk of placental abruption
the risk of preterm delivery
the extent of vaginal bleeding
the woman's ability to attend secondary care in an emergency.
For pregnant women who present with unexplained vaginal bleeding, offer to carry out placental localisation by ultrasound if the placental site is not known.
1.4.20For pregnant women with unexplained vaginal bleeding who are admitted to hospital, consider corticosteroids for fetal lung maturation if there is an increased risk of preterm birth within 48 hours. Take into account gestational age (see the section on maternal corticosteroids in the NICE guideline on preterm labour and birth).
1.4.21Consider discussing the increased risk of preterm birth with women who have unexplained vaginal bleeding.
Terms used in this guidelineThis section defines terms that have been used in a particular way for this guideline.
Bonding and emotional attachmentBonding is the positive emotional and psychological connection that the parent develops with the baby.
Emotional attachment refers to the relationship between the baby and parent, driven by innate behaviour and which ensures the baby's proximity to the parent and safety. Its development is a complex and dynamic process that is dependent on sensitive and emotionally attuned parent interactions supporting healthy infant psychological and social development and a secure attachment. Babies form attachments with a variety of caregivers but the first, and usually most significant of these, will be with the mother and/or father.
Continuity of carerHaving continuity of carer means that a trusting relationship can be developed between the woman and the healthcare professional who cares for her. Better Births, a report by the National Maternity Review, defines continuity of carer as consistency in the midwifery team (between 4 and 8 individuals) that provides care for the woman and her baby throughout pregnancy, labour and the postnatal period. A named midwife coordinates the care and takes responsibility for ensuring that the needs of the woman and her baby are met throughout the antenatal, intrapartum and postnatal periods.
For the purpose of this guideline, definition of continuity of carer in the Better Births report has been adapted to include not just the midwifery team but any healthcare team involved in the care of the woman and her baby. It emphasises the importance of effective information transfer between the individuals within the team. For more information, see the NHS Implementing Better Births: continuity of carer.
PartnerPartner refers to the woman's chosen supporter. This could be the baby's father, the woman's partner, family member or friend, or anyone who the woman feels supported by and wishes to involve in her antenatal care.
Structured fetal movement awareness packagesThe structured fetal movement awareness package described in the Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM) trial consisted of:
an e-learning education package for all clinical staff about the importance of a recent change in the frequency of fetal movements and how to manage reduced fetal movements
a leaflet given to pregnant women at 20 weeks of pregnancy to raise awareness of the importance of monitoring fetal movements and reporting reduced movements
a structured management plan for hospitals following reporting of reduction in fetal movement including cardiotocography, measurement of liquor volume and a growth scan (umbilical artery doppler was encouraged if available).
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