Antenatal care for uncomplicated pregnancies overview


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Antenatal care for uncomplicated pregnancies overview
NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: http://pathways.nice.org.uk/pathways/antenatal-care-for-uncomplicated-pregnancies
NICE Pathway last updated: 29 January 2020
This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations.

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

1 Pregnant woman
No additional information
2 Principles 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.
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.
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.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart. Antenatal care quality standard
1. Services – access to antenatal care
2. Services – continuity of care
4. Risk assessment – body mass index
6. Risk assessment – gestational diabetes

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview 8. Risk assessment – intermediate risk of venous thromboembolism 9. Risk assessment – high risk of venous thromboembolism

NICE Pathways

3 Information and support

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 vitamin D deficiency, and details of the Healthy Start programme exercise, including pelvic floor exercises place of birth (see planning place of birth) pregnancy care pathway breastfeeding, including workshops participant-led antenatal classes further discussion of all antenatal screening discussion of mental health issues (see what NICE says on antenatal and postnatal mental health)
Before or at 36 weeks: 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

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

newborn screening tests postnatal self-care awareness of 'baby blues' and postnatal depression.
At 38 weeks: options for management of prolonged pregnancy.
See also schedule of appointments for further information on antenatal appointments.
This can be supported by information such as 'The pregnancy book' (Department of Health 2007) and the use of other relevant resources such as UK National Screening Committee publications and the MIDIRS information leaflets.
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 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.

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

See also what NICE says on maternal and child nutrition.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart. Antenatal care quality standard 1. Services – access to antenatal care Nutrition: improving maternal and child nutrition quality standard 1. Healthy eating in pregnancy Intrapartum care 1. Choosing birth setting

4 Appointments and records

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 7 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.
NICE has written information for the public on antenatal care for uncomplicated pregnancies.
See also schedule of appointments for further information on antenatal appointments.

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

See what NICE says on risk assessment for diabetes in pregnancy. Records 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.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart. Antenatal care quality standard 1. Services – access to antenatal care 3. Services – record keeping

5 Clinical examination

Weight and BMI
Maternal weight and height should be measured at the booking appointment, and the woman's BMI should be calculated (weight [kg]/height[m2]).
Repeated weighing during pregnancy should be confined to circumstances in which clinical management is likely to be influenced.
See what NICE says on obesity.
Gestational age assessment
Pregnant women should be offered an early ultrasound scan between 10 weeks days and 13 weeks 6 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.

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

Crown‒rump length measurement should be used to determine gestational age. If the crown‒rump length is above 84 mm, the gestational age should be estimated using head circumference.
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.
See what NICE says on domestic violence and abuse and pregnancy and complex social factors: service provision.
Mental disorders
For information on the assessment and management of mental health problems in women up to 1 year after childbirth see what NICE says on antenatal and postnatal mental health.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Antenatal care quality standard
4. Risk assessment – body mass index

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

6 Lifestyle considerations
See Antenatal care for uncomplicated pregnancies / Antenatal care for uncomplicated pregnancies: lifestyle considerations
7 Managing common symptoms
Nausea and vomiting
Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks 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.
NICE has published an evidence summary on doxylamine/pyridoxine (Xonvea) for treating nausea and vomiting of pregnancy.
NICE has published a clinical knowledge summary on nausea and vomiting in pregnancy. This practical resource is for primary care professionals (it is not formal NICE guidance).
Dyspepsia
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.
NICE has published a clinical knowledge summary on pregnancy-associated dyspepsia.

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview

NICE Pathways

Constipation

Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation.
NICE has published a clinical knowledge summary on constipation, and explains how to manage it for pregnant or breastfeeding women.
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.
For more information see what NICE says on pregnant women with varicose veins.
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.
See what NICE says on medicines optimisation.

Antenatal care for uncomplicated pregnancies
© NICE 2020. All rights reserved. Subject to Notice of rights.

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Antenatal care for uncomplicated pregnancies overview