The National Institute for Health and Care Excellence (NICE) has published draft guidance on routine antenatal care for healthy women.
Key recommendations are as follows:
Overarching principles
- Ensure that women have the information they need to make informed decisions about their care, in different languages and different formats.
- Supporting women to make decisions about their care.
- Involve partners as per the woman’s wishes.
- Provide routine and emergency contact details.
Organisation
- Ensure antenatal care is available in straightforward ways, including self-referral.
- First antenatal visit with a midwife should take place by 10+0 weeks of pregnancy.
- For referrals later than 9+0 weeks, first appointment should take place within 2 weeks, if possible.
- Plan 10 routine antenatal visits for nulliparous women.
- Plan 7 routine appointments for parous women.
- Ensure interpreting services are available.
- Information should be shared with the woman’s GP.
First antenatal appointment
- Assess:
- medical, obstetric and family history;
- previous or current mental health concerns;
- current and recent medication;
- allergies;
- occupation;
- home situation;
- lifestyle; and
- risk for female genital mutilation.
- Measure:
- Height, weight and body mass index.
- Full blood count, blood group and rhesus D status.
- Offer the following screening programmes:
- NHS infectious diseases in pregnancy screening programme (HIV, syphilis and hepatitis B)
- NHS sickle cell and thalassaemia screening programme
- NHS foetal anomaly screening programme.
- Assess risk for pre-eclampsia and advise those at risk to take aspirin.
- Refer to NHS stop smoking services if appropriate.
- Consider assessing for cardiac conditions if there are concerns.
- Women with a medical concern should be referred to an obstetrician.
- Carry out a risk assessment for foetal growth restriction (and again in the second trimester).
Ultrasound
- Offer an ultrasound scan for between 11+2 weeks and 14+1 weeks to:
- determine gestational age;
- detect multiple pregnancy; and
- screen for Down’s syndrome, Edward’s syndrome and Patau’s syndrome.
- Offer ultrasound for between 18+0 weeks and 20+6 weeks to:
- screen for foetal anomalies and
- determine placental location.
- Do not routinely offer ultrasound after 28 weeks.
- Discuss the baby’s movements with the mother after 24+0 weeks.
- Offer symphysis fundal height measurement at each appointment after 24+0 weeks for singleton pregnancies.
Breech presentation
- Perform abdominal palpation at all appointments after 36+0 weeks for singleton pregnancies.
- In suspected breech presentation, perform an ultrasound scan to confirm.
- For women with an uncomplicated singleton pregnancy with breech presentation confirmed after 36+0 weeks:
- explain to women that turning the baby from a breech to a head down position makes a normal, head-first vaginal birth more likely and
- offer external cephalic version.
Sleep
- Advise women not to sleep on their back after 28 weeks as there may be a link between sleeping on her back and stillbirth in late pregnancy.
Nausea and vomiting
- Suggest ginger for mild-moderate nausea and vomiting.
- Discuss the advantages and disadvantages of pharmacological options.
- For women with hyperemesis gravidarum:
- offer antiemetics and intravenous fluids (ideally on an outpatient basis) and
- consider acupressure.
Heartburn
- Give information about lifestyle and dietary factors.
- Consider a trial of antacid or alginate.
Symptomatic vaginal discharge
- Advise that vaginal discharge is common during pregnancy, but if it is accompanied by symptoms such as itching, soreness, an unpleasant smell, or pain on passing urine, it needs to be investigated.
- Consider carrying out a vaginal swab.
- If a sexually transmitted infection is suspected, consider appropriate investigations.
- Offer vaginal imidazole for vaginal candidiasis.
- Consider oral or vaginal antibiotics for bacterial vaginosis.
Pelvic girdle pain
- Consider referral to physiotherapy services.
Unexplained vaginal bleeding
- 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.
- Assess:
- risk of placental abruption,
- risk of preterm delivery,
- extent of bleeding, and
- ability to attend secondary care in an emergency.
- Carry out placental localisation by ultrasound.
- For pregnant women who are admitted to hospital, consider corticosteroids for foetal lung maturity if there is an increased risk of preterm birth within 48 hours, taking into account gestational age.
Venous thromboembolism
- Assess risk factors at the first antenatal appointment and after any hospital admission or significant health event during pregnancy.
- Women at risk of should be referred to an obstetrician.
Gestational diabetes
- Assess risk factors at the first antenatal appointment.
- If risk factors are present, conduct an oral glucose tolerance test between 24+0 weeks and 28+0 weeks.
Pre-eclampsia and hypertension
- Assess risk factors for pre-eclampsia at the first antenatal appointment and advise those at risk to take aspirin.
- Measure blood pressure at every routine appointment.
- For women under 20+0 weeks with hypertension, follow the NICE guideline on hypertension in pregnancy.
- Women over 20+0 weeks with a first episode of hypertension (≥140/90 mmHg) should be seen by secondary care within 24 hours.
- Women with severe hypertension (≥160/110 mmHg) should be seen by secondary care services on the same day.
- Offer urine dipstick test for proteinuria at every routine appointment.
The draft guidance is now open for public consultation until 24 March 2021.
This article originally appeared on Univadis, part of the Medscape Professional Network.
