National Collaborating Centre for Women’s and Children’s Health Antenatal care routine care for the healthy pregnant woman Clinical Guideline March 2008 Funded to produce guidelines for the NHS by NICE RCOG Press 2008 RCOG Press Published by the Royal College of Obstetricians and Gynaecologists. To purchase further copies and for a complete list of RCOG Press titles, visit: www.rcogbookshop.com Antenatal care Antenatal care routine care for the healthy pregnant woman Clinical Guideline March 2008 Clinical Guideline March 2008 Antenatal care Other NICE guidelines produced by the National Collaborating Centre for Women’s and Children’s Health include: • Fertility: assessment and treatment for people with fertility problems • Caesarean section • Type 1 diabetes: diagnosis and management of type 1 diabetes in children and young people • Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception • Urinary incontinence: the management of urinary incontinence in women • Heavy menstrual bleeding • Feverish illness in children: assessment and initial management in children younger than 5 years • Urinary tract infection in children: diagnosis, treatment and long-term management • Intrapartum care: care of healthy women and their babies during childbirth • Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years • Surgical management of otitis media with effusion in children • Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period Guidelines in production include: • Induction of labour (update) • Surgical site infection • Diarrhoea and vomiting in children under 5 • When to suspect child maltreatment • Meningitis and meningococcal disease in children • Neonatal jaundice • Idiopathic constipation in children • Hypertension in pregnancy • Socially complex pregnancies • Autism in children and adolescents Enquiries regarding the above guidelines can be addressed to: National Collaborating Centre for Women’s and Children’s Health King’s Court Fourth Floor 2–16 Goodge Street London W1T 2QA enquiries@ncc-wch.org.uk A version of this guideline for pregnant women, their partners and the public is available from the NICE website (www.nice.org.uk/CG062) or from NICE publications on 0845 003 7783; quote reference number N1483. Antenatal care routine care for the healthy pregnant woman National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence March 2008 This is a partial update of the 2003 guideline. New or amended sections are indicated by a grey bar in the margin. RCOG Press Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG www.rcog.org.uk Registered charity no. 213280 First published 2008, revised reprint June 2008 (page 98), further revised reprint June 2009 (pages 3 and 28) 2nd edition © 2008 National Collaborating Centre for Women’s and Children’s Health 1st edition published in 2003 No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use. While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising. ISBN 978-1-904752-46-2 NCC-WCH Editor: Andrew Welsh Original design: FiSH Books, London Typesetting: Andrew Welsh Proofreading: Katharine Timberlake (Reedmace Editing) Index: Jan Ross (Merrall-Ross (Wales) Ltd) Printed by Henry Ling Ltd, The Dorset Press, Dorchester DT1 1HD iii Contents Guideline Development Group membership and acknowledgements vi Original (2003) version: Guideline Development Group vi Ackno wledgments vi Stakeholder organisations vi Peer reviewers vii 2008 update: Guideline Development Group viii Ackno wledgments viii Stakeholder organisations viii Abbreviations xii Glossar y of terms xvi 1 Intr oduction 1 1.0 Introduction 1 1.1 Aim of the guideline 1 1.2 Areas outside the remit of the guideline 2 1.3 For whom is the guideline intended? 3 1.4 Who has developed the guideline? 3 1.5 Who has dev eloped the guideline update? 3 1.6 Guideline methodology 4 2 Summary of recommendations and care pathw ay 12 2.1 Key priorities for implementation (key recommendations) 12 2.2 Summary of recommendations 13 2.3 Key priorities for research 25 2.4 Additional research recommendations 26 2.5 Care pathway 27 3 Woman-centred care and informed decision making 37 3.1 Introduction 37 3.2 Provision of information 37 3.3 Antenatal classes 58 4 Provision and organisation of care 67 4.1 Who provides care? 67 4.2 Continuity of care 67 4.3 Where should antenatal appointments take place? 69 4.4 Documentation of care 69 4.5 Frequency of antenatal appointments 70 4.6 Gestational age assessment 73 4.7 What should happen at antenatal appointments? 78 5 Lifestyle considerations 82 5.1 Ph ysiological, psychosocial and emotional changes in pregnanc y 82 5.2 Maternity health benefits 82 5.3 Working during pregnancy 82 5.4 Dietary information and education 83 5.5 Nutritional supplements 84 5.6 Food-acquired infections 92 5.7 Prescribed medicines 93 5.8 Over-the-counter medicines 93 5.9 Complementary therapies 93 5.10 Exer cise in pregnancy 94 5.11 Sexual intercourse in pregnancy 95 5.12 Alcohol and smoking in pregnancy 95 5.13 Cannabis use in pregnanc y 101 5.14 Air tr avel during pregnanc y 101 5.15 Car travel during pregnanc y 102 5.16 Trav elling abroad during pregnancy 103 2008 update iv Antenatal care 6 Management of common symptoms of pregnancy 106 6.1 Nausea and vomiting in early pregnancy 106 6.2 Heartburn 108 6.3 Constipation 109 6.4 Haemorrhoids 110 6.5 V aricose veins 110 6.6 Vaginal discharge 111 6.7 Backache 112 6.8 Symphysis pubis dysfunction 113 6.9 Carpal tunnel syndrome 113 7 Clinical e xamination of pregnant women 114 7.1 Measurement of weight and body mass index 114 7.2 Breast examination 115 7.3 Pelvic examination 115 7.4 F emale genital mutilation 116 7.5 Domestic violence 117 7.6 Psychiatric screening 118 8 Scr eening for haematological problems 120 8.1 Anaemia 120 8.2 Blood grouping and red cell alloantibodies 121 8.3 Screening for haemoglobinopathies (sickle cell disease and thalassaemia) 122 9 Scr eening for fetal anomalies 134 9.1 Screening for structur al anomalies 134 9.2 Screening for Do wn’s syndrome 154 10 Screening for infections 180 10.1 Asymptomatic bacteriuria 180 10.2 Asymptomatic bacterial vaginosis 183 10.3 Chlam ydia trachomatis 184 10.4 Cytomegalovirus 193 10.5 Hepatitis B virus 194 10.6 Hepatitis C virus 194 10.7 HIV 195 10.8 Rubella 197 10.9 Streptococcus group B 198 10.10 Syphilis 200 10.11 T oxoplasmosis 202 11 Scr eening for clinical problems 205 11.1 Gestational diabetes 205 11.2 Pre-eclampsia 218 11.3 Preterm birth 228 11.4 Placenta praevia 251 12 F etal growth and w ellbeing 253 12.1 Introduction and background 253 12.2 Diagnostic v alue for predicting SGA babies 255 12.3 Diagnostic v alue for predicting LGA babies 265 12.4 Effecti veness studies 267 12.5 Health economics evidence 274 12.6 F etal wellbeing 275 13 Management of specific clinical conditions 278 13.1 Pregnancy after 41 weeks 278 13.2 Pregnancy after 42 weeks 279 13.3 Breech presentation at term 280 14 Antenatal assessment tool 282 14.1 Introduction and background 282 14.2 Systematic review of the evidence 282 14.3 Developing an antenatal assessment tool 286 Appendix A Declarations of interest 290 Appendix B Economic model: asymptomatic bacteriuria scr eening programme 292 Appendix C Economic model: streptococcus group B screening pr ogramme 294 Appendix D Economic model: syphilis screening programme 295 2008 2008 update 2008 v Appendix E Economic model: screening for congenital cardiac malformations 297 Appendix F Economic model: screening and treatment of gestational diabetes 3 05 Appendix G Economic model: monitoring fetal growth 3 31 Appendix H Training and equipment standards for ultrasound screening in pregnancy 336 Appendix I Further information 337 Appendix J Family origin questionnaire 338 Appendix K Deleted material from the 2003 version 339 2.1 Summary of recommendations 339 2.3 Algorithm – Antenatal care: routine care for the healthy pregnant woman 341 3.1 Provision of information 344 3.2 Antenatal education 345 4.6 Gestational age assessment: LMP and ultrasound 347 5.5 Nutritional supplements 348 5.12 Alcohol and smoking in pregnancy 348 8.2 Screening for sic kle cell disorders and thalassaemia 349 9 Screening for fetal anomalies 350 9.1 Screening for structural anomalies 351 9.2 Screening for Do wn’s syndrome 353 10.1 Asymptomatic bacteriuria 357 10.3 Chlamydia trachomatis 357 11.1 Gestational diabetes mellitus 358 11.2 Pre-eclampsia 361 11.3 Preterm birth 364 11.4 Placenta praevia 365 12.2 Measurement of symph ysis–fundal distance 365 12.7 Umbilical and uterine artery Doppler ultr asound 366 15 A uditable standards 368 Appendix 1 369 Refer ences (2003 version) 380 References (2008 update) 397 Inde x 408 Sear ch strategies CD-ROM Excluded studies CD-ROM Evidence tables CD-ROM 2008 update 2008 update Contents vi Guideline Development Group membership and acknowledgements Original (2003) version Guideline Development Group Peter Brocklehurst Group Leader Belinda Ackerman Midwife Brian Cook General Practitioner Joanie Dimavicius Consumer Helen Edwards Radiographer Gill Gyte Consumer Shahid Husain Neonatologist Gwyneth Lewis Confidential Enquiry into Maternal Deaths Tim Overton Obstetrician Gill Roberts RCOG Patient Information Specialist Stephen Robson Obstetrician Julia Sanders Midwife Anne White General Practitioner Jane Thomas Director NCC-WCH Sue Lee Research Fellow NCC-WCH Jennifer Gray Informatics Specialist NCC-WCH Natalie Terry Administrative support NCC-WCH Hannah Rose Douglas Health Economist, London School of Hygiene and Tropical Medicine Dimitra Lambrelli Health Economist London School of Hygiene and Tropical Medicine Acknowledgments Additional support was also received from: • David Asomani, Anna Burt, Heather Brown, Susan Davidson, Gregory Eliovson, Susan Murray and Alex McNeil at the National Collaborating Centre for Women’s and Children’s Health. • Stravros Petrou at the National Perinatal Epidemiology Unit and Kirsten Duckitt at the John Radcliffe Hospital, Oxford. • Members of the previous Antenatal Care Guideline Development Group: John Spencer (Chairman), J Bradley, Jean Chapple, R Cranna, Marion Hall, Marcia Kelson, Catherine McCormack, Ralph Settatree, Lindsay Smith, L Turner, Martin Whittle, Julie Wray. • The Patient Involvement Unit, whose glossary we have amended for use in this guideline. • The Three Centres Consensus Guidelines on Antenatal Care, Mercy Hospital for Women, Monash Medical Centre (Southern Health) and The Royal Women’s Hospital (Women’s & Children’s Health), Melbourne 2001, whose work we benefited from in the development of this guideline. Stakeholder organisations Action on Pre-Eclampsia (APEC) Antenatal Results and Choices Association for Continence Advice (ACA) Association for Improvements in Maternity Services (AIMS) vii Association of Radical Midwives Association of the British Pharmaceuticals Industry(ABPI) Aventis Pasteur MSD Brighton Healthcare NHS Trust British Association of Paediatric Surgeons British Association of Perinatal Medicine British Dietetic Association British Maternal and Fetal Medicine Society British Medical Association British National Formulary British Psychological Society BUPA Chartered Society of Physiotherapy CIS’ters Department of Health Evidence based Midwifery Network Faculty of Public Health Medicine Gateshead Primary Care Trust General Medical Council Group B Strep Support Health Development Agency Hospital Infection Society Isabel Medical Charity Maternity Alliance Mental Health Foundation Monmouthshire Local Health Group National Childbirth Trust NHS Quality Improvement Scotland Nottingham City Hospital Obstetric Anaesthetists Association Royal College of General Practitioners Royal College of General Practitioners Wales Royal College of Midwives Royal College of Nursing Royal College of Obstetricians and Gynaecologists Royal College of Paediatrics and Child Health Royal College of Pathologists Royal College of Psychiatrists Royal College of Radiologists Royal Pharmaceutical Society of Great Britain Royal Society of Medicine Scottish Intercollegiate Guidelines Network (SIGN) Sickle Cell Society Society and College of Radiographers STEPS Survivors Trust Twins and Multiple Births Association (TAMBA) UK Coalition of People Living with HIV and AIDS UK National Screening Committee UK Pain Society United Kingdom Association of Sonographers Victim Support Welsh Assembly Government (formerly National Assembly for Wales) West Gloucestershire Primary Care Trust Young Minds Peer reviewers Susan Bewley, Leanne Bricker, Howard Cuckle, Andrew Dawson, Viv Dickinson, Grace Edwards, Jason Gardosi, Duncan Irons, Deirdre Murphy, Tim Reynolds, Jilly Rosser, Lindsay Smith, John Spencer, Pat Tookey, Derek Tuffnell, Gavin Young. Guideline Development Group membership and acknowledgements viii Antenatal care 2008 update Guideline Development Group GDG members Rhona Hughes Group Leader Jane Anderson Ultrasound Radiographer Chris Barry General Practitioner Marie Benton Service User Representative Jennifer Elliott Service User Representative Nina Khazaezadeh Consultant Midwife and Supervisor of Midwives Rachel Knowles Medical Research Council Clinical Public Health Research Fellow Tim Overton Consultant Obstetrician Katie Yiannouzis Head of Midwifery National Collaborating Centre for Women’s and Children’s Health (NCC-WCH) staff Rupert Franklin Work-Programme Coordinator Eva Gautam-Aitken Work-Programme Coordinator Paul Jacklin Senior Health Economist Rajesh Khanna Senior Research Fellow Rintaro Mori Research Fellow Francesco Moscone Health Economist Debbie Pledge Senior Information Scientist Jeff Round Health Economist Anuradha Sekhri Research Fellow Roz Ullman Senior Research Fellow Martin Whittle Co-Director in Women’s Health External advisers Guy Rooney Genitourinary Medicine Specialist Anne Longton Health Visitor Fiona Ford Dietician Jane Hawdon Consultant Neonataologist Acknowledgments Additional support was also received from: • Anna Bancsi, Angela Kraut, Moira Mugglestone and Martin Dougherty at the NCC-WCH • Allison Streetly, Programme Director for the NHS Sickle Cell and Thalassaemia Screening Programme. • Andrew Welsh, freelance guideline editor, whose editorial support was invaluable in the production of this guideline. • Group Dynamics, who provided the voting equipment for the Assessment Tool consensus meeting. Stakeholder organisations Academic Division of Midwifery, University of Nottingham Action on Pre-Eclampsia Addenbrooke’s NHS Trust All Wales Birth Centre Group Antenatal Screening Wales Association for Psychoanalytic Psychotherapy in the NHS Association for Spina Bifida & Hydrocephalus (ASBAH) Association of Breastfeeding Mothers Association of British Clinical Diabetologists Association of Chartered Physiotherapists in Women’s Health 2008 update [...]... Key priorities for implementation (key recommendations) Antenatal 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 Lifestyle considerations All women should be informed at the booking appointment... of antenatal care originated in the early decades of the 20th century The pattern of visits recommended at that time (monthly until 30 weeks, then fortnightly to 36 weeks and then  Antenatal care weekly until delivery) is still recognisable today It has been said that antenatal care has escaped critical assessment.4 Both the individual components and composite package of antenatal care should conform... on these less straightforward or measurable outcomes (such as the benefit foregone from ending pregnancy) The economic analysis of screening methods in the guideline has not been able to consider the following: • the value to the woman of being given information about the health of her future child • the value of being able to plan appropriate services for children who are born with disabilities • the. .. and comprehensive information on the antenatal care of the healthy woman with an uncomplicated singleton pregnancy It provides evidence-based information for clinicians and pregnant women to make decisions about appropriate treatment in specific circumstances The guideline will complement the Children’s National Service Frameworks (England and Wales) (2004) which provides standards for service configuration,... 2008 update Bias The appointment where the woman enters the maternity care pathway, characterised by information giving and detailed history-taking to help the woman choose the most appropriate antenatal care pathway Also includes measurement of height, weight, blood pressure and blood tests for determining blood group, rubella status and haemoglobin level Blood and urine samples for screening may... to explore women’s preferences for different aspects of their antenatal care The economic evidence presented in this guideline is not a systematic review of all the economic evidence around antenatal care It was decided that the health economic input into the guideline should focus on specific topics where the GDG thought that economic evidence would help them to inform their decisions This approach... data considered to be the closest to current UK opportunity cost (the value of the resources used, rather than the price or charge) The approach adopted for this guideline was for the health economic analysis to focus on specific areas Topics for economic analysis were selected on the following basis by the GDG • Does the proposed topic have major resource implications? • Is there a change of policy... with Antenatal care A study comparing two or more interventions in which the participants, upon completion of the course of one treatment, are switched to another For example, for a comparison of treatments A and B, half the participants are randomly allocated to receive them in the order A, B and half to receive them in the order B, A A problem with this study design is that the effects of the first... could be seen as a limitation of the analysis presented in this guideline The consequences of this are discussed in Appendices B to G as appropriate Health economics for the 2008 update The aim of the economic input into the guideline was to inform the GDG of potential economic issues relating to antenatal care The health economist helped the GDG by identifying topics within the guideline that might benefit... specificity First contact The initial appointment where the woman first meets a healthcare professional with a confirmed pregnancy This appointment includes referral into the maternity care pathway and is an opportunity for information giving to ensure the woman is able to make informed decisions about her pregnancy care, including all antenatal screening and to raise awareness about health-related issues that . Collaborating Centre for Women’s and Children’s Health Antenatal care routine care for the healthy pregnant woman Clinical Guideline March 2008 Funded to produce guidelines for the NHS by NICE RCOG Press 2008 RCOG. obesity. Booking The appointment where the woman enters the maternity care pathway, characterised by information giving and detailed history-taking to help the woman choose the most appropriate antenatal care. N1483. Antenatal care routine care for the healthy pregnant woman National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical