Antenatal care

Around 660,000 women give birth in England and Wales each year. The risk of maternal death during pregnancy and up to six weeks after birth is¹ :

• White women: 8/100,000.

• Black women: 34/100,000.

• Mixed ethnic background: 25/100,000.

• Asian women (not including Chinese women): 15/100,000.

The stillbirth rate is¹ :

• White babies: 34/10,000.

• Black babies: 74/10,000.

• Asian babies: 53/10,000.

Women living in the most deprived areas (15/100,000)¹ :

• 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).

General principles²

Women should be fully involved in decisions about their care and treatment in pregnancy and therefore need to be given the knowledge to make informed decisions. Where appropriate, a woman's partner and family should be involved and informed and their views and values respected. Good communication is crucial at every step in pregnancy.

Keeping women informed

Care should be centred on the pregnant woman; the aim should be to keep her fully informed on the progress of her pregnancy and to provide her with evidence-based information and support to make informed decisions.

At first contact with a health professional, she should be given:

• Information on where antenatal care will be offered and by whom, including choice of providers where available and information about antenatal screening.

• Information about folic acid supplementation.

• Lifestyle advice including:

  • Food hygiene and safe eating in pregnancy.

  • Smoking cessation.

  • Advice about avoidance of alcohol and illicit drugs in pregnancy.

• Medication advice (review of safety of any current medication in pregnancy and avoidance of over-the-counter (OTC) medication which may not be used in pregnancy).

Other general principles

• In uncomplicated pregnancies, midwife/GP care should normally be offered, with specialist care readily available when complications occur.

• The patient should be seen by a small group of professionals who provide continuity of care.

• Antenatal care should be readily and easily accessible and should be in an environment which enables women to discuss confidential issues such as domestic violence, sexually transmitted infections, mental health problems or recreational drug use.

• Allow women the time and space to bring up issues of concern to them. Ask about the home situation and the support they have in pregnancy and will have in the immediate postnatal period. Establish if there are other children at home.

• Patients should carry their own notes. Maternity records should be structured to help provide the required level of evidence-based care.

• Assessment of gestational age should be based on an early ultrasound scan rather than the last menstrual period. Such scans should be offered to all women between 10 and 13 weeks and help to ensure:

  • Consistency of gestational age assessments.

  • Multiple pregnancy is picked up early.

  • Improved accuracy of Down's screening assessment.

  • Sensible decisions on induction of labour after 41 weeks.

Mental health³

Be alert to mental health problems - current or potential. The National Institute for Health and Care Excellence (NICE) updated its advice on mental health in pregnancy and the postnatal period in 2014. Guidance advises healthcare professionals - at a woman's first contact with primary care, her booking visit and during the early postnatal period - to:

• Consider asking questions to screen for depression and anxiety as part of a general discussion about a woman's mental health and well-being.

• Ask about any past or present severe mental illness.

• Ask about past or present treatment by a specialist mental health service, including inpatient care

• Ask about any severe perinatal mental illness in a first-degree relative.

In women with established mental health issues, consider the needs of partners, families and carers that might affect a woman with a mental health problem in pregnancy and the postnatal period. These include:

• The welfare of the baby and other dependent children and adults.

• The role of the partner, family or carer in providing support.

• The potential effect of any mental health problem on the woman's relationship with her partner, family or carer.

Additional care

At the first antenatal visit, identify women who may need additional care and refer to an appropriate specialist. Indications for additional care during pregnancy include:

• Cardiac disease, including hypertension.

• Renal disease.

• Hepatic disease.

• Diabetes mellitus or other endocrine disorder.

• Psychiatric disorders (requiring medication) or a history of psychiatric disorders.

• Haematological disorders, including sickle cell disease, thalassaemia, or thromboembolic disease.

• Autoimmune disorders, such as antiphospholipid syndrome.

• Epilepsy requiring anticonvulsant drugs.

• Cancer.

• Severe asthma (for example, requiring hospital admission or frequent courses of oral corticosteroids).

• HIV or hepatitis B infection.

• Cystic fibrosis.

• Obesity (BMI of 35 kg/m² or more at first contact) or underweight (BMI less than 18 kg/m² at first contact).

• Recreational drug use, such as heroin, cocaine (including crack cocaine) and ecstasy.

Additional care may also be required for women at higher risk of developing complications including those:

• Aged 40 years or older.

• Who smoke.

• Who are particularly vulnerable (for example, 18 years or younger) or lack social support.

• With a family history of a genetic disorder.

• With a multiple pregnancy.

Women who have experienced any of the following in previous pregnancies also require additional care:

• Recurrent miscarriage (three or more consecutive pregnancy losses) or a mid-trimester loss.

• Preterm birth (before 34 weeks).

• Severe pre-eclampsia, HELLP syndrome (haemolysis, elevated liver enzyme levels, and low platelet count), or eclampsia.

• Rhesus isoimmunisation or other significant blood group antibodies.

• Uterine surgery, including caesarean section, myomectomy, or cone biopsy.

• Antepartum haemorrhage or postpartum haemorrhage on two or more occasions.

• Retained placenta on two or more occasions.

• Puerperal psychosis.

• Grand multiparity (having previously delivered five or more infants who achieved a gestational age of at least 24 weeks).

• Stillbirth or neonatal death.

• A small-for-gestational-age infant (less than fifth percentile).

• A large-for-gestational-age infant (greater than 95th percentile).

• An infant weighing less than 2500 g or more than 4500 g.

• An infant with a congenital anomaly (structural or chromosomal).

Advice: employment⁴

Pregnant employees have four main legal rights:

• Paid time off for antenatal care.

• Maternity leave.

• Maternity pay or maternity allowance.

• Protection against unfair treatment, discrimination or dismissal. It is against the law to discriminate against anyone because they are pregnant.

Employers must give pregnant employees time off for antenatal care and pay their normal rate for this time off. The father or pregnant woman's partner has the right to unpaid time off work to go to two antenatal appointments. 'Antenatal care' is not just medical appointments - it can also include antenatal or parenting classes if they've been recommended by a doctor or midwife.

Employers cannot change a pregnant employee's contract terms and conditions without agreement - if they do they are in breach of contract.

Pregnancy-related illnesses: maternity leave and Statutory Maternity Pay will start automatically if the employee is off work for a pregnancy-related illness in the four weeks before the baby is due - it does not matter what has been previously agreed.

Compulsory maternity leave: if the employee is not taking Statutory Maternity Leave, they must take two weeks off after the baby is born - or four weeks if they work in a factory.

Telling the employer about the pregnancy: employees must tell their employer about the pregnancy at least 15 weeks before the beginning of the week the baby is due. If this is not possible (eg, because they did not know they were pregnant), the employer must be told as soon as possible. Employees must also tell the employer when they want to start their Statutory Maternity Leave and Statutory Maternity Pay. Employees cannot take time off for antenatal appointments until they've told the employer about the pregnancy.

When the employee tells their employer they're pregnant, the employer should assess the risks to the employee and their baby. Risks could be caused by:

• Heavy lifting or carrying.

• Standing or sitting for long periods without adequate breaks.

• Exposure to toxic substances.

• Long working hours.

Where there are risks, the employer should take reasonable steps to remove them. For example, offering the employee different work or changing their hours. The employer should suspend the employee on full pay if they cannot remove any risks. For example, offering suitable alternative work.

Pregnant employees who think they're at risk but their employer disagrees should talk to their health and safety or trade union representative. If your employer still refuses to do anything, talk to your doctor or contact the Health and Safety Executive.

Further information for expectant mothers and for employers is available on the Health and Safety Executive website⁵ .

The maternity certificate MAT B1 form should be signed to enable a pregnant woman to claim Statutory Maternity Pay (SMP) from her employer or Maternity Allowance (MA) from Jobcentre Plus⁶ . It can be signed from 20 weeks before the estimated week of delivery. Doctors or midwives are required to sign this free of charge.

Advice: nutrition^{2 7}

Pregnant women should be encouraged to have a normal, balanced, healthy diet. Because of the dangers of toxoplasmosis and listeriosis, women should avoid:

• Uncooked meat or fish.

• Raw or partially cooked eggs, and products such as fresh mayonnaise which may contain raw eggs.

• Milk that has not been pasteurised.

• Soft cheeses which are mould-ripened or made from unpasteurised milk, such as Brie and Camembert, or soft blue-veined cheeses such as Danish Blue.

• Pâté of any sort.

• Raw shellfish.

• Shark, swordfish and marlin (due to high mercury levels).

• More than two portions per week of oily fish.

• Unwashed fruit or vegetables. (Fruit and vegetables should be washed due to the small risk of toxoplasma from soil.)

Vegetarians, and especially vegans, may be at risk of nutritional deficiencies and may need to be referred to a dietician for advice about obtaining all nutrients through diet.

Women should be cautioned to avoid many herbal preparations and teas; their use and safety in pregnancy have not been studied.

Advice: supplements

Pregnant women, women with a child under 12 months and children aged up to 4 years who are receiving Healthy Start vouchers are entitled to free Healthy Start vitamins (folic acid, vitamins C and D) for eligible women. Women who are not eligible for Healthy Start can obtain the supplements from their local pharmacy^{8 9} .

When using multivitamin preparations, women should use those which are specifically designed for pregnancy.

Folic acid¹⁰

• Use any appropriate opportunity to advise women who may become pregnant that they can most easily reduce the risk of having a baby with a neural tube defect by taking folic acid supplements.

• Advise them to take 400 micrograms (μg) daily before pregnancy and throughout the first 12 weeks, even if they are already eating foods fortified with folic acid or rich in folate.

• Encourage women to take folic acid supplements and to eat foods rich in folic acid (eg, fortified breakfast cereals and yeast extract) and to consume foods and drinks rich in folate (eg, peas and beans and orange juice).

• Prescribe folic acid 5 mg/day for women who are planning a pregnancy, or are in the early stages of pregnancy, if they:

  • Have a neural tube defect (or their partner).

  • Have had a previous baby with a neural tube defect

  • Have a family history of neural tube defects (or their partner).

  • Have diabetes.

Vitamin D¹¹

Adequate vitamin D stores during pregnancy and breastfeeding are important for the health of both mother and baby. All women should be advised to take vitamin D supplements (10 micrograms = 400 units per day). This is particularly important for¹² :

• Housebound women or those who have limited exposure to sunlight, such as women who usually remain covered when outdoors - eg, for cultural reasons.

• South Asian, African, Caribbean or Middle Eastern family origin.

Caution with vitamin D supplementation is needed in women with sarcoidosis or renal disease.

Iron¹²

Iron should not be offered routinely as it has no benefit to either mother or baby and may cause constipation and other side-effects. Women should be given dietary advice, encouraging dietary intake of iron. Iron supplements may be required to treat anaemia. See the separate article Anaemia in Pregnancy.

Anaemia is defined in pregnancy as:

• Hb <110 g/L in the first trimester.

• Hb <105 g/L in the second and third trimesters.

• Hb <100 g/L postpartum.

If established, it should be treated with 100-200 mg of oral elemental iron per day for three months and for at least six weeks postpartum.

Vitamin A¹²

Women should be warned that high levels of vitamin A may be teratogenic and therefore that they should avoid extra supplementation. Liver and liver products may contain high levels of vitamin A and should be avoided.

Advice: medication¹³

Advise women to use as few medicines as possible during pregnancy and only when benefit outweighs risk. This includes OTC medication and complementary therapies, as few products have been shown to be definitely safe during pregnancy. Ideally review any regular medication pre-conception but, if this has not been done, as soon as possible in pregnancy.

Advice: lifestyle^{2 12}

Exercise

Women who exercise regularly should be advised to continue to do so. Those who are inactive should start a gentle programme of regular exercise. Moderate exercise has not been shown to cause any harm but the patient should be warned of the dangers of highly energetic and contact sports that would risk damage to the abdomen, falls or excessive joint stress.

Scuba diving should be avoided, as it can cause fetal birth defects and fetal decompression disease.

Sexual intercourse

This has not been shown to cause any harm during pregnancy. It may be advisable to avoid it if there is risk of preterm rupture of membranes or if there is placenta praevia, although evidence is limited¹⁴ .

Alcohol²

High levels of alcohol consumption during pregnancy may result in fetal alcohol syndrome (FAS).

It is recommended that women be advised not to drink any alcohol at all during pregnancy. Women should be advised 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

• Therefore the safest approach is to avoid alcohol altogether to minimise risks to the baby.

Smoking¹⁵

Smoking in pregnancy is associated with a large number of adverse effects in pregnancy including:

• Intrauterine growth restriction and low birth weight.

• Miscarriage and stillbirth.

• Premature delivery.

• Placental problems.

NICE guidelines encourage GPs and midwives to be proactive in helping with smoking cessation. Women should be asked about smoking at their first contact and at each subsequent appointment if they are smokers. Offer referral to NHS smoking services. Information about the risks of smoking to the fetus and the mother and then of secondhand smoke to a newborn baby should be given.

There is little information on the use of nicotine replacement therapy (NRT) in pregnancy but smoking gives a greater dose of nicotine and also exposes mother and fetus to other toxins. It is likely to be safer than smoking in mothers for whom non-pharmacological interventions have failed. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription. Advise pregnant women using nicotine patches to remove them before going to bed.

Neither bupropion nor varenicline should be prescribed in pregnancy.

Recreational drug use^{16 17}

The number of women misusing drugs has increased considerably in the past few decades and many are in their child-bearing years. Though pregnancy may act as a catalyst for change and present a 'window of opportunity', drug misusers may not use general health services until late into pregnancy and this increases the health risks for both the mother and child.

• A multidisciplinary approach is essential. Most localities will have a clearly defined drug dependency service with a readily accessible entry point.

• Cocaine use in pregnancy is particularly serious and there is no substitute. It has been associated with spontaneous abortion, placental abruption, premature birth, low birth weight and sudden infant death syndrome. There is conflicting evidence regarding fetal abnormalities.

• Opiate use is associated with increased incidence of intrauterine growth restriction and preterm delivery. This contributes to an increased rate of low birth weight and perinatal mortality. Maintenance treatment with an opiate substitute improves outcomes.

• Women addicted to heroin who wish to become pregnant should be urged to enter a detoxification programme before conception and, if not, then at least be stabilised on methadone. Buprenorphine is also used as a substitute with apparently similar outcomes in pregnancy¹⁸ .

• HIV and hepatitis B screening is carried out in all pregnant women in the UK but is especially important in known IV drug users. Hepatitis C screening is also recommended in this group.

• The use of cannabis may be harmful to the fetus and is also associated with smoking and should be discouraged.

• Cochrane reviews have found no convincing evidence for psychosocial interventions¹⁹ .

Travel²⁰

Flying is associated with increased risk of deep vein thrombosis (DVT) but it is not known if the risk is further increased in pregnancy. Use of compression hosiery reduces the risk in the general population. Also discuss vaccinations and travel insurance if travelling abroad. There is no evidence that flying is associated with an increased risk of miscarriage or premature labour. Airlines have their own guidance about from what gestation pregnant women should not fly for practical reasons.

Advise on proper use of seat belts for car travel, with belts above and below bump rather than over it.

Treating symptoms of early pregnancy²

Nausea and vomiting of pregnancy generally resolve by 12-20 weeks of gestation. Cochrane reviews have been unable to find evidence of efficacy and safety for any of the many treatments used²¹ . There was little evidence found for the efficacy of acupuncture. Ginger, antiemetics and antihistamines are often used.

Heartburn may be alleviated by taking small meals and raising the head of the bed. It may need antacids. The manufacturers of Gaviscon® state it is safe for use in pregnancy.

Constipation is another common symptom in early pregnancy. Women should be advised on diet to combat this (fluids and increasing dietary fibre) or may use bran or wheat fibre supplementation.

See also the separate article Common Problems in Pregnancy.

Antenatal appointments²

Information about the timing and function of the appointments should be given to the woman in writing with the chance to discuss them with her doctor or midwife. Appointments should have a focus and structure and include routine tests where possible.

They should also be used as an opportunity to give information and allow the patient to ask questions and discuss any topics which are of concern to them. Domestic violence is a subject that pregnant women should be encouraged to discuss openly.

First (booking) appointment

This should be before 12 weeks of pregnancy, ideally by week 10. There may need to be two appointments because of the volume of information required to be imparted. All information should initially be offered verbally and backed up in writing with an opportunity to discuss and ask questions.

• Measure and record the woman's height, weight, and body mass index.

• Blood pressure and proteinuria. Identify women with risk factors for pre-eclampsia.

• Discuss all antenatal screening tests and ultrasound scans. Offer ultrasound scans:

  • Dating scan: normally between 10 and 13 weeks.

  • Fetal anomaly scan: normally between 18 and 20 weeks.

• Offer fetal screening for Down's Syndrome.

• Offer blood tests to check blood group.

• Offer maternal screening for anaemia, red cell alloantibodies (such as anti-D and less commonly anti-c and anti-Kell), and haemoglobinopathies (such as sickle cell disease and thalassaemias). Testing for red cell alloantibodies and haemoglobinopathies should be offered as early as possible in pregnancy (ideally by 10 weeks). The type of haemoglobinopathy screening depends on the local prevalence of the disorder. The NHS Sickle Cell and Thalassaemia Screening Programme advises that in high-prevalence areas (more than 1.5 infants born with sickle cell disease per 10,000 births):

  • All pregnant women be offered screening for sickle cell disorders, thalassaemia, and other haemoglobin variants.

  • All partners of women who are identified as carriers of significant traits be offered screening.

  • The NHS Family Origin Questionnaire (FOQ) be used to determine the need for the partner to be screened.

• In low-prevalence areas (1.5 infants or fewer born with sickle cell disease per 10,000 births):

  • All pregnant women be offered screening for thalassaemia using routine erythrocyte indices.

  • An FOQ should be used to assess the risk of either the woman or her partner being a carrier for sickle cell, thalassaemia, and other haemoglobin variants.

  • If a woman is defined as high risk, she should be offered additional screening. The partners of all identified carrier mothers (regardless of family origin) should be offered screening for sickle cell, other haemoglobin variants, and thalassaemia.

• Offer maternal screening for:

  • Hepatitis B virus and HIV infection.

  • Asymptomatic bacteriuria (to reduce the risk of pyelonephritis by early intervention).

  • Syphilis: if left untreated, this may lead to miscarriage, stillbirth, preterm birth, and other complications.

  • Chlamydia screening should not be offered as part of routine antenatal care. However, if the woman is younger than 25 years of age, inform her about the high prevalence of chlamydial infection in this age group and give details of her local National Chlamydia Screening Programme.

• Offer influenza vaccination for all women pregnant during the influenza season (October to January). Outside of these dates, use clinical judgement to assess whether the woman should be immunized.

• Pertussis vaccination should be offered between 16 and 32 gestational weeks to maximise the likelihood that the baby will be protected from birth. Vaccination is probably best offered on or after the fetal anomaly scan at around 20 weeks. Women may still be immunised after week 32 of pregnancy but this may not offer as high a level of passive protection to the baby²² .

• Arrange testing for gestational diabetes for women with any of the following risk factors:

  • Body mass index above 30 kg/m².

  • Previous macrosomic infant weighing 4.5 kg or above.

  • Previous gestational diabetes.

  • Family history of diabetes (first-degree relative with diabetes).

  • Family origin with a high prevalence of diabetes such as South Asian (specifically women whose country of family origin is India, Pakistan, or Bangladesh), black Caribbean, or Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon, or Egypt).

• Give lifestyle advice including advice on nutrition, supplements (including folic acid and vitamin D), diet, and food hygiene.

• Give written advice on the different stages of the baby's development. The Department of Health has published The Pregnancy Book, which discusses the different stages of the baby's development and most other aspects of pregnancy⁷ .

• Give information on:

  • Antenatal classes available locally, including those run by the National Childbirth Trust.

  • Breastfeeding, including workshops available locally.

  • Maternity benefits.

  • Exercise, including pelvic floor exercises.

  • The Healthy Start Programme⁹ .

  • Options for the place of birth.

• Give the woman her hand-held maternity records. The woman should take these records to each subsequent antenatal appointment (including secondary care) and any visit to a healthcare professional.

• Discuss mental health issues.

Further appointments

The NICE guideline details the advised appointment schedule and procedures for each stage. Briefly it is as follows.

• 16 weeks: this appointment should be used to review the results of earlier tests, discuss them with the patient and if necessary institute a changed pattern of antenatal care having identified those women who require additional care.

• 18-20 weeks: this appointment is for women who have agreed to a test for fetal structural anomalies. If the placenta is found to cover the internal cervical os, the scan should be repeated at 32 weeks.

• 25 weeks: this appointment is for nulliparous women and, as well as routine procedures (eg, BP check, proteinuria screening) should include measurement and plotting of symphysis-fundal height.
  NB: all appointments from this point should routinely include measurement and plotting of symphysis-fundal height.

• 28 weeks: this appointment is for all pregnant women and, in addition to routine procedures, they should be offered another opportunity to screen for anaemia and atypical red cell allo-antibodies, investigate and treat haemoglobin <105 g/L and offer anti-D prophylaxis for rhesus-negative women.

• 31 weeks: this appointment is for nulliparous women and, as well as routine procedures, it should include a review of screening tests performed at 28 weeks, with reassessment of care needs and identification of those who need extra care.

• 34 weeks: this appointment is for all pregnant women. Information surrounding preparation for labour and birth should be given, including discussion of pain relief and recognition of active labour. The second dose of anti-D should be offered to rhesus-negative women. Routine measurements of BP and fundal height should be made and urinalysis carried out. Results of 28-week screening tests should be discussed.

• 36 weeks: this appointment is for all pregnant women and, in addition to routine procedures, should allow for checking of the position of the fetus with external cephalic version offered to women with a breech presentation. Information should be given surrounding issues such as breastfeeding, care of the new baby, postnatal depression and vitamin K.

• 38 weeks: this appointment is for all pregnant women for all routine procedures to be performed.

• 40 weeks: this appointment is for nulliparous women for all routine procedures to be performed.

• 41 weeks: this appointment is for all pregnant women who have not yet given birth and, in addition to all routine procedures, the woman should be offered a membrane sweep and/or induction of labour.