At the booking appointment (ideally by 10 weeks)
- 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 tests, including screening for haemoglobinopathies, hepatitis B virus, HIV, and syphilis, fetal anomalies (including screening for Down's syndrome, Edwards' syndrome and Patau's syndrome and the 18+0 to 20+6 week fetal anomaly scan)
- at booking appointment (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 (www.healthystart.nhs.uk)
- exercise, including pelvic floor exercises
- place of birth
- pregnancy care pathway
- breastfeeding, including workshops
- participant-led antenatal classes
- further discussion of all antenatal screening - discussion of mental health issues
- at this appointment:
- identify women who may need additional care (see linked item) and plan pattern of care for the pregnancy
- check blood group and rhesus D status
- offer screening for haemoglobinopathies, anaemia, red-cell alloantibodies, hepatitis B virus, HIV, and syphilis
- offer screening for asymptomatic bacteriuria
- inform pregnant women younger than 25 years about the high prevalence of chlamydia infection in their age group, and give details of their local National Chlamydia Screening Programme (www.chlamydiascreening.nhs.uk)
- offering screening for fetal anomalies (including screening for Down's syndrome, Edwards' syndrome and Patau's syndrome and the 18+0 to 20+6 week fetal anomaly scan) offer early ultrasound scan for gestational age assessment
- measure height, weight and calculate body mass index
- measure blood pressure and test urine for proteinuria
- offer screening for gestational diabetes and pre-eclampsia using risk factors
- identify women who have had genital mutilation
- ask about any past or present severe mental illness or psychiatric treatment
- ask about mood to identify possible depression
- ask about the woman's occupation to identify potential risks
- at the booking appointment, for women who choose to have screening, the following tests should be arranged:
- blood tests (for checking blood group and rhesus D status and screening for haemoglobinopathies, anaemia, red-cell alloantibodies, hepatitis B virus, HIV, and syphilis), ideally before 10 weeks
- urine tests (to check for proteinuria and screen for asymptomatic bacteriuria)
- ultrasound scan to determine gestational age using:
- crown-rump length measurement between 10 weeks 0 days and 14 weeks and 1 day
- head circumference if crown-rump length is above 84.0 millimetres
- Down's syndrome, Edwards' syndrome and Patau's syndrome screening using:
- 'combined test' when the CRL is between 45.0mm and 84.0mm (equates to at 11 weeks 2 days to 14 weeks 1 day
- Down's syndrome only
- serum screening test ( quadruple test) at 14 weeks 2 days to 20 weeks 0 days
- ultrasound screening for 11 physical conditions between 18 weeks 0 days and 20 weeks 6 days
* antenatal rubella susceptibility screening has been withdrawn, as this is no longer offered on the NHS (2). 2 MMR vaccinations preconception or postnatally is advocated as the best protection from rubella infection.
- follows reviews of the evidence by the UK National Screening Committee (UK NSC) in 2003 and 2012. On both occasions the evidence showed that screening for rubella susceptibility during pregnancy did not meet the UK NSC criteria for a screening programme (3)
NICE have provided very similar information in a "patient-centred" style (4):
- involve partners according to the woman' s wishes and tell the woman that her partner is welcome to attend appointments and classes.
- ensure that interpreting services are available if needed. Use independent interpreters rather than the woman's family members or friends.
- provide a safe environment for discussions.
- all discussions should support shared decision making and be tailored to the woman's needs, preferences and stage of pregnancy.
- update the woman's antenatal records with details of history, test results, examination findings, medicines and discussions.
- consider reviewing the woman’s previous medical records if needed, including records held by other healthcare providers.
- if the woman agrees, contact her GP to share information about the pregnancy and potential concerns or complications during pregnancy.
Taking a history - Ask the woman about:
- her general health and wellbeing
- whether she has any concerns that she would like to discuss - also ask her partner about this, if present
- her obstetric history, and the medical and family history of both biological parents
- previous or current mental health concerns, including any severe mental illness, trauma or psychiatric treatment
- current and recent medicines, health supplements and herbal remedies
- allergies
- her nutrition and diet, physical activity, smoking status, alcohol consumption and recreational drug use
- her occupation, discussing any risks and concerns
- her family and home situation - if she is alone, also ask about domestic abuse
- her support network, including other people who may be involved in the baby's care
- any health or other issues affecting her partner or family members that may be significant for her health and wellbeing
- contact details for her partner and her next of kin
If a woman books late in pregnancy, also ask about the reasons for the late booking because it may reveal social, psychological or medical issues that need to be addressed.
Examinations and investigations
If the appointment is face to face, offer:
- to measure height, weight and body mass index
- a blood test for full blood count, blood group and rhesus D status
- to take blood pressure using a device validated for use in pregnancy (for urgent actions to take when a woman's blood pressure is very high [160/110 mmHg or more], see managing complications and common problems.)
- a urine dipstick test for proteinuria
Assess the woman's risk of:
- gestational diabetes
- pre-eclampsia
- fetal growth restriction
- venous thromboembolism
- female genital mutilation (FGM).
Take follow-up actions as listed below
Follow-up actions
- for women with a high blood pressure (140/90 mmHg or more), see managing complications and common problems
- if a woman is at risk of gestational diabetes, offer referral for an oral glucose tolerance test to take place between 24+0 and 28+0 weeks in line with the NICE guideline on diabetes in pregnancy
- advise those at risk of pre-eclampsia to take aspirin.
- if there are any medical concerns or review of long-term medicines is needed, refer the woman to an obstetrician or other relevant doctor. This includes referring the woman for a clinical assessment to detect cardiac conditions if her personal or family history suggest this may be needed.
- take appropriate action about risks of FGM
- other medical concerns
Also see managing complications and common problems for:
- heartburn
- nausea and vomiting
- smoking
- unexplained vaginal bleeding
Screening programmes
Offer screening programmes for:
- HIV
- syphilis
- hepatitis B
- sickle cell
- thalassaemia
- fetal anomalies
Tell the woman she can accept or decline any part of these screening programmes
Providing information - discuss and give information on the following in a non-judgemental, compassionate and personalised way:
- changes during pregnancy, including:- baby's development -what to expect at each stage of the pregnancy -physical, emotional and relationship changes -support between partners
- staying healthy during pregnancy, including:-immunisation for flu, whooping cough and other infections, in line with relevant guidelines -infections that can impact on the baby (for example, groupB streptococcus)-reducing the risk of infections -safe use of medicines and health supplements -mental health-lifestyle, including nutrition and diet, physical activity, smoking, alcohol consumption and recreational drug
use - antenatal care, covering:-what antenatal care involves and why it is important -which healthcare professionals will be involved in the
appointments -when and where appointments will take place -which screening programmes are offered and why - contact details for the:-midwifery team, for non-urgent advice -maternity service, for urgent concerns such as pain and bleeding
- resources and support for expectant and new parents
- how to get in touch with local or national peer support services.
Scheduling antenatal appointments
Plan:
- 10 appointments for nulliparous women
- 7 appointments for parous women. If the woman opts to have them, book ultrasound scans to take place:
- between 11+2 weeks and 14+1 weeks and
- between 18+0 weeks and 20+6 weeks
Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social and emotional needs. Be aware that closer monitoring may be needed for women and their babies from black, Asian and minority ethnic family origins, and those who live in deprived areas, because they are at an increased risk of adverse outcomes
Reference: