Schedule of Appointments in Routine Antenatal Care

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Schedule of appointments inroutine antenatal care

A NICE pathway brings together all NICE guidance, qualitystandards and materials to support implementation on a specictopic area. The pathways are interactive and designed to be usedonline. This pdf version gives you a single pathway diagram anduses numbering to link the boxes in the diagram to the associatedrecommendations.

To view the online version of this pathway visit:

http://pathways.nice.org.uk/pathways/antenatal-care

Pathway last updated: 22 November 2011Copyright NICE 2011. All rights reserved

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Schedule of appointments in routine antenatal care NICE Pathways

Antenatal care pathwayCopyright NICE 2011. Pathway last updated: 22 November 2011

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1 Healthy pregnant woman

No additional information

2 First contact with a healthcare professional

Give specific information on:

folic acid supplements

food hygiene, including how to reduce the risk of a food-acquired infection (see also lifestyle

advice)

lifestyle, including smoking cessation (see the smoking pathway), recreational drug use and

alcohol consumption (see also lifestyle advice)

all antenatal screening, including screening for haemoglobinopathies, the anomaly scan

and screening for Down's syndrome, as well as risks, benefits and limitations of the

screening tests. See below for more details (see providing antenatal information for more

about giving antenatal information).

Haemoglobinopathies

Offer information about screening for sickle cell diseases and thalassaemias, including carrier

status and the implications of these, to pregnant women at the first contact with a healthcareprofessional.

Anomaly scan

At the first contact with a healthcare professional, give women information about the purpose

and implications of the anomaly scan to enable them to make an informed choice as to whether

or not to have the scan. The purpose of the scan is to identify fetal anomalies and allow:

reproductive choice (termination of pregnancy)

parents to prepare (for any treatment/disability/palliative care/termination of pregnancy)

managed birth in a specialist centre

intrauterine therapy.

Inform women of the limitations of routine ultrasound screening and that detection rates vary by

the type of fetal anomaly, the woman's body mass index and the position of the unborn baby at

the time of the scan.



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Down's syndrome

Offer information about screening for Down's syndrome at the first contact with a healthcare

professional. This will provide the opportunity for further discussion before embarking on

screening. Specific information should include:

the screening pathway for both screen positive and screen negative results

the decisions that need to be made at each point along the pathway and their

consequences

the fact that screening does not provide a definitive diagnosis and a full explanation of the

risk score obtained following testing

information about chorionic villus sampling and amniocentesis

balanced and accurate information about Down's syndrome.

All pregnant women should be offered screening for Down's syndrome. Women should

understand that it is their choice to embark on screening for Down's syndrome.

3 Booking appointment and arranging screening

See Antenatal care / Booking appointment and arranging screening

4 16 weeks

Review, discuss and record the results of screening tests (see below).

Measure blood pressure and test urine for proteinuria.

Investigate a haemoglobin level below 11 g/100 ml and consider iron supplements.


The routine anomaly scan (see anomaly scan at 18 to 20 weeks [See page 5]).Blood grouping and red cell alloantibodies

Offer women with clinically significant atypical red-cell alloantibodies referral to a specialist

centre for further investigation and advice on subsequent antenatal management.

If a pregnant woman is rhesus D-negative (see routine antenatal anti-D prophylaxis [See page

6]), consider offering partner testing to determine whether the administration of anti-D

prophylaxis is necessary.



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Haemoglobinopathies

If the woman is identified as a carrier of a clinically significant haemoglobinopathy, offer the

father of the baby counselling and appropriate screening without delay.

For more details about haemoglobinopathy variants refer to the NHS Sickle Cell &

Thalassaemia Screening Programme.

Down's syndrome

If a pregnant woman receives a screen positive result for Down's syndrome, offer rapid access

to appropriate counselling by trained staff.

5 Anomaly scan at 18 to 20 weeks

If the woman chooses, an ultrasound scan should be performed between 18 weeks 0 days and

20 weeks 6 days to detect structural anomalies.

If an anomaly is detected during the anomaly scan, inform women to enable them to make an

informed choice as to whether they wish to continue with the pregnancy or have a termination of

pregnancy.

Fetal echocardiography involving the four-chamber view of the fetal heart and outflow tracts is

recommended as part of the routine anomaly scan.

When routine ultrasound screening is performed to detect neural tube defects, alpha-fetoprotein

testing is not required.

For a woman whose placenta extends across the internal cervical os, offer another scan at 32

weeks.

Participation in regional congenital anomaly registers and/or UK National Screening Committee-

approved audit systems is strongly recommended to facilitate the audit of detection rates.

Soft markers for Down's syndrome

Do not routinely use the routine anomaly scan (at 18 weeks 0 days to 20 weeks 6 days) for

Down's syndrome screening using soft markers.



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Do not use the presence of an isolated soft marker, with the exception of increased nuchal fold,

on the routine anomaly scan, to adjust the a priori risk for Down's syndrome.

The presence of an increased nuchal fold (6 millimetres or above) or two or more soft markers

on the routine anomaly scan should prompt the offer of a referral to a fetal medicine specialist or

an appropriate healthcare professional with a special interest in fetal medicine.

Implementation

The following implementation tools are relevant to this part of the pathway.

Antenatal care: audit support

Antenatal care: costing report

Antenatal care: costing template

Antenatal care: slide set

6 25 weeks for nulliparous women only

Measure blood pressure and test urine for proteinuria.Measure and plot symphysisfundal height.

7 28 weeks


Offer a second screening for anaemia and atypical red-cell alloantibodies.

Investigate a haemoglobin level below 10.5 g/100 ml and consider iron supplements.

Offer anti-D prophylaxis to women who are rhesus D-negative (see below).

Measure and plot symphysisfundal height.

Routine antenatal anti-D prophylaxis

Routine antenatal anti-D prophylaxis (RAADP) is recommended as a treatment option for all

pregnant women who are rhesus D (RhD) negative and who are not known to be sensitised to

the RhD antigen.



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When a decision has been made to give RAADP, the preparation with the lowest associated

cost should be used. This cost should take into account the lowest acquisition cost available

locally and costs associated with administration.

These recommendations are from Routine antenatal anti-D prophylaxis for women who are

rhesus D negative (NICE technology appraisal guidance 156).

NICE has written a booklet for patients and the public explaining the guidance on routine

antenatal anti-D prophylaxis.


Review, discuss and record the results of screening tests undertaken at 28 weeks.Measure blood pressure and test urine for proteinuria.


9 34 weeks

Review, discuss and record the results of screening tests undertaken at 28 weeks.


Offer a second dose of anti-D prophylaxis to women who are rhesus D-negative (see 28weeks [See page 6])1.


Give women specific information on preparation for labour and birth, including the birth

plan, recognising active labour and coping with pain.

Give pregnant women evidence-based information about caesarean section during the

antenatal period, because about one in four women will have a caesarean section. Include

information such as:

indications (such as presumed fetal compromise, 'failure to progress' in labour,

breech presentation)

what the procedure involves

associated risks and benefits

implications for future pregnancies and birth after caesarean section.

10 36 weeks




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1 This applies only to the two-dose regimens; for more information see Routine antenatal anti-D prophylaxis for

women who are rhesus D negative (NICE technology appraisal guidance 156).


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Assess fetal presentation by abdominal palpation at 36 weeks or later, when presentation is

likely to influence the plans for the birth. Do not offer routine assessment of presentation by

abdominal palpation before 36 weeks because it is not always accurate and may be

uncomfortable.

Confirm suspected fetal malpresentation by an ultrasound assessment.

Offer all women who have an uncomplicated singleton breech pregnancy at 36 weeks

external cephalic version. Exceptions include women in labour and women with a uterine

scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding and medical

conditions.

Where it is not possible to schedule an appointment for external cephalic version at 37

weeks, it should be scheduled at 36 weeks.

Give specific information by 36 weeks on:

Breastfeeding: technique and good management practices, such as detailed in the UNICEF

Baby Friendly Initiative.

Care of the new baby, vitamin K prophylaxis and newborn screening tests.

Postnatal self-care, awareness of 'baby blues' and postnatal depression (see the postnatal

care pathway).

11 38 weeks




Options for management of prolonged pregnancy (see the induction of labour pathway).




Further discussion of management of prolonged pregnancy (see the induction of labour

pathway).

13 41 weeks

For more information see the induction of labour pathway .



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For women who have not given birth by 41 weeks:

offer a membrane sweep

offer induction of labour

measure blood pressure and test urine for proteinuria

measure and plot symphysisfundal height.

14 42 weeks

From 42 weeks, offer women who decline induction of labour increased monitoring (at least

twice-weekly cardiotocography and ultrasound examination of maximum amniotic pool depth).

15 Intrapartum care pathway

See Intrapartum care / Intrapartum care overview



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Source guidance

Caesarean section. NICE clinical guideline 132 (2011)

Antenatal care: routine care for the healthy pregnant woman. NICE clinical guideline 62 (2008)

Routine antenatal anti-D prophylaxis for women who are rhesus D negative. NICE technology

appraisal guidance 156 (2008)

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after carefulconsideration of the evidence available. Those working in the NHS, local authorities, the wider

public, voluntary and community sectors and the private sector should take it into account when

carrying out their professional, managerial or voluntary duties. Implementation of this guidance

is the responsibility of local commissioners and/or providers. Commissioners and providers are

reminded that it is their responsibility to implement the guidance, in their local context, in light of

their duties to avoid unlawful discrimination and to have regard to promoting equality of

opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent

with compliance with those duties.

Copyright

Copyright National Institute for Health and Clinical Excellence 2011. All rights reserved. NICE

copyright material can be downloaded for private research and study, and may be reproduced

for educational and not-for-profit purposes. No reproduction by or for commercial organisations,

or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE

National Institute for Health and Clinical Excellence

Level 1A, City Tower

Piccadilly Plaza

Manchester

M1 4BT

www.nice.org.uk



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Documents

Schedule of Appointments in Routine Antenatal Care