Antenatal care

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.

At 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 smoking: stopping in pregnancy and after childbirth.

• 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.

If 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.

If 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.

Plan 10 routine antenatal appointments with a midwife or doctor for nulliparous women. (See schedule of appointments.)

Plan 7 routine antenatal appointments with a midwife or doctor for parous women. (See schedule of appointments.)

Also 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.

Ensure 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.

Those responsible for planning and delivering antenatal services should aim to provide continuity of carer.

Ensure that there is effective and prompt communication between healthcare professionals who are involved in the woman's care during pregnancy.

A 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.

When 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.

Be 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 smoking: stopping in pregnancy and after childbirth. Also see the NICE guideline on smokeless tobacco: South Asian communities.

Ask 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.

Assess 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.

Refer 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.

Refer 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.

After 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.

At 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.

At every antenatal contact, update the woman's antenatal records to include details of history, test results, examination findings, medicines and discussions.

At 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 sickle cell and thalassaemia screening programme

• 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:

• anti-D prophylaxis to rhesus-negative women in line with NICE's technology appraisal guidance on routine antenatal anti-D prophylaxis for women who are rhesus D negative (see also NICE's diagnostics guidance on high-throughput non-invasive prenatal testing for fetal RHD genotype)

• a blood test to check full blood count, blood group and antibodies.

If there are any unexpected results from examinations or investigations, offer referral according to local pathways and ensure appropriate information provision and support.

Assess the woman's risk factors for venous thromboembolism at the first antenatal (booking) appointment, and after any hospital admission or significant health event during pregnancy. Consider using guidance by an appropriate professional body, for example, the Royal College of Obstetricians and Gynaecologists' guideline on reducing the risk of venous thromboembolism during pregnancy.

For pregnant women who are admitted to a hospital or a midwife-led unit, see the section on interventions for pregnant women and women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks in the NICE guideline on venous thromboembolism in over 16s.

For women at risk of venous thromboembolism, offer referral to an obstetrician for further management.

At the first antenatal (booking) appointment, assess the woman's risk factors for gestational diabetes in line with the recommendations on gestational diabetes risk assessment in the NICE guideline on diabetes in pregnancy.

If a woman is at risk of gestational diabetes, offer referral for an oral glucose tolerance test to take place between 24+0 weeks and 28+0 weeks in line with the recommendations on gestational diabetes risk assessment and the recommendations on gestational diabetes testing in the NICE guideline on diabetes in pregnancy.

At the first antenatal (booking) appointment and again in the second trimester, assess the woman's risk factors for pre-eclampsia, and advise those at risk to take aspirin in line with the section on antiplatelet agents in the NICE guideline on hypertension in pregnancy.

Measure and record the woman's blood pressure at every routine face-to-face antenatal appointment using a device validated for use in pregnancy, and following the recommendations on measuring blood pressure in the NICE guideline on hypertension in adults.

For women under 20+0 weeks with hypertension, follow the recommendations on the management of chronic hypertension in pregnancy in the NICE guideline on hypertension in pregnancy.

Refer women over 20+0 weeks with a first episode of hypertension (blood pressure of 140/90 mmHg or higher) to secondary care to be seen within 24 hours. See the recommendations on diagnosing hypertension in the NICE guideline on hypertension in adults.

Urgently refer women with severe hypertension (blood pressure of 160/110 mmHg or higher) to secondary care to be seen on the same day. The urgency of the referral should be determined by an overall clinical assessment.

Offer a urine dipstick test for proteinuria at every routine face-to-face antenatal appointment.

Offer 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.

Offer 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.

If there are concerns that the symphysis fundal height is large for gestational age, consider an ultrasound scan for fetal growth and wellbeing.

If 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.

Do not routinely offer ultrasound scans after 28 weeks for uncomplicated singleton pregnancies.

Discuss 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.

Offer abdominal palpation at all appointments after 36+0 weeks to identify possible breech presentation for women with a singleton pregnancy.

If breech presentation is suspected on abdominal palpation, offer an ultrasound scan to determine the presentation.

For women with an uncomplicated singleton pregnancy with breech presentation confirmed after 36+0 weeks:

• discuss the different options available and their benefits, risks and implications, including:

  • external cephalic version (to turn the baby from bottom to head down)

  • breech vaginal birth

  • elective caesarean birth

• for women who prefer cephalic (head-down) vaginal birth, offer external cephalic version.
  
  Also see the recommendations on breech presentation in the NICE guideline on caesarean birth, and the recommendations on breech presenting in labour in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies.

When 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.

Ensure 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.

Women's decisions should be respected, even when this is contrary to the views of the healthcare professional.

When 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.

Check 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.

At the first antenatal (booking) appointment, discuss antenatal care with the woman (and her partner) and provide her schedule of antenatal appointments.

At 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, weight management before, during and after pregnancy, smoking: stopping in pregnancy and after childbirth, and the section on pregnant women who misuse substances (alcohol and/or drugs) in the NICE guideline on pregnancy and complex social factors.

At 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.

See the NICE guideline on pelvic floor dysfunction for guidance on:

• providing information about pelvic floor dysfunction (recommendation 1.1.6)

• pelvic floor muscle training during and after pregnancy.

After 24 weeks, discuss babies' movements (see also recommendation 1.2.34).

Before 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).

After 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.

From 38 weeks, discuss prolonged pregnancy and options on how to manage this, in line with the NICE guideline on inducing labour.

See 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.

Provide appropriate information and support for women whose baby is considered to be at an increased risk of neonatal admission.

Offer nulliparous women (and their partners) antenatal classes that include topics such as:

• preparing for labour and birth

• supporting each other throughout the pregnancy and after birth

• common events in labour and birth

• how to care for the baby

• 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)

• planning and managing their baby's feeding (also see the section on planning and supporting babies' feeding in the NICE guideline on postnatal care).

Consider antenatal classes for multiparous women (and their partners) if they could benefit from attending (for example, if they have had a long gap between pregnancies, or have never attended antenatal classes before).

Ensure that antenatal classes are welcoming, accessible and adapted to meet the needs of local communities. Also see the section on young pregnant women aged under 20 in the NICE guideline on pregnancy and complex social factors.

Discuss 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.

Advise 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.

Explain to the woman that there may be a link between going to sleep on her back and stillbirth in late pregnancy (after 28 weeks).

Reassure women that mild to moderate nausea and vomiting are common in pregnancy, and are likely to resolve before 16 to 20 weeks.

Recognise that by the time women seek advice from healthcare professionals about nausea and vomiting in pregnancy, they may have already tried a number of different interventions.

For pregnant women with mild‑to‑moderate nausea and vomiting who prefer a non-pharmacological option, suggest that they try ginger.

When considering pharmacological treatments for nausea and vomiting in pregnancy, discuss the advantages and disadvantages of different antiemetics with the woman. Take into account her preferences and her experience with treatments in previous pregnancies. See table 1 on the advantages and disadvantages of different pharmacological treatments for nausea and vomiting in pregnancy to support shared decision making.

For pregnant women with nausea and vomiting who choose a pharmacological treatment, offer an antiemetic (see table 1 on the advantages and disadvantages of different pharmacological treatments for nausea and vomiting in pregnancy).

For pregnant women with moderate‑to‑severe nausea and vomiting:

• consider intravenous fluids, ideally on an outpatient basis

• consider acupressure as an adjunct treatment.

Consider inpatient care if vomiting is severe and not responding to primary care or outpatient management. This will include women with hyperemesis gravidarum. For more information on managing hyperemesis gravidarum, see the Royal College of Obstetricians and Gynaecologists' guideline on the management of nausea and vomiting of pregnancy and hyperemesis gravidarum. Also see the section on venous thromboembolism.

Give information about lifestyle and dietary changes to pregnant women with heartburn in line with the section on common elements of care in the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults.

Consider a trial of an antacid or alginate for pregnant women with heartburn.

Advise 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.

Consider carrying out a vaginal swab for pregnant women with symptomatic vaginal discharge if there is doubt about the cause.

If a sexually transmitted infection is suspected, consider arranging appropriate investigations.

Offer vaginal imidazole (such as clotrimazole or econazole) to treat vaginal candidiasis in pregnant women.

Consider oral or vaginal antibiotics to treat bacterial vaginosis in pregnant women in line with the NICE guideline on antimicrobial stewardship.

For 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.

For 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.

For 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).

Consider discussing the increased risk of preterm birth with women who have unexplained vaginal bleeding.