Introduction

Pregnant women are offered antenatal appointments throughout the pregnancy to monitor the wellbeing of the woman and the baby, share information, discuss any concerns, plan for birth and prepare for the postnatal period. The routine content of each appointment depends on the phase of the pregnancy. In this report, the information and discussions underpinning the recommendations on content of antenatal appointments are documented.

Methods and process

This report was developed using the methods and process described in Developing NICE guidelines: the manual, in particular section 8 Linking to other guidance.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

Content of antenatal care appointments essentially covers what is discussed and what assessments, examinations, investigations or interventions are done during the antenatal appointments. Much of the content of antenatal appointments is already covered by other relevant sources, such as:

• other evidence reviews covered by this guideline, which were developed using the systematic reviewing methodology, including cost effectiveness and resource impact considerations
• other NICE guidelines, which were developed using the systematic reviewing methodology, including cost effectiveness and resource impact considerations
• national legislation or policy, such as guidance or programmes by the UK National Screening Committee, Joint Committee for Vaccination and Immunisation and Public Health England.

Based on the process for linking to other guidance outlined in the section 8 of the Developing NICE guidelines: the manual, the committee agreed that the issues covered by reviews in other NICE guidelines relevant for this question were similar enough, covered the topics appropriately and the evidence underpinning the recommendations is unlikely to have changed significantly since these reviews were developed. Therefore, they felt confident that it is appropriate to cross refer to these other guidelines. Similarly, they were confident that the evidence review processes underpinning the recommendations from the UK National Screening Committee and the Joint Committee for Vaccination and Immunisation were up to date and appropriate.

In addition to the content covered by these sources, the committee identified gaps which should not be missed from the recommendations so that beneficial activities would not be inadvertently lost from current usual care and so that the guideline makes sense to those implementing it. They discussed if these gaps could be addressed by consensus-based decision making without reviewing evidence. The criteria for making recommendations addressing these gaps without reviewing new evidence, via informal committee consensus to reflect best practice, was that there is no clinical uncertainty and no significant resource impact, or the potential limited resource impact could be justifiably off set by benefits down the line, such as improved outcomes, avoidance of serious adverse outcomes or addressing inequalities issues according to NICE principles. The committee generally agreed that the identified gaps could be addressed by consensus-based decision making on current best practice. As a result, it was agreed no separate systematic review was required for this topic.

The process for developing recommendations on the content of antenatal appointments was as follows:

• The technical team with advice from the NICE quality assurance team initially used the 2008 NICE guideline on antenatal care for uncomplicated pregnancies (CG62), Appendix D: Antenatal appointments (schedule and content) as the basis for what the content currently is.
• The technical team then mapped out other relevant sources (such as those listed above) that cover elements of the content of antenatal appointments.
• Based on this initial mapping, the committee then met to discuss:

  • if and how the different elements of the content of antenatal appointments are sufficiently covered in the sources identified and if there are any other relevant accredited sources
  • if a recommendation could and should be made without reviewing new evidence, via informal committee consensus, on anything that is not covered by the sources identified but which is listed in the 2008 NICE guideline (CG62) as part of antenatal appointments, taking into consideration the criteria for this outlined above
  • if any of the elements of the content of antenatal care appointments listed in the 2008 guideline (CG62) may no longer be needed or relevant
  • if there are any additional elements not covered in the 2008 guideline (CG62) which are relevant, reflect current best practice, or are important for the implementation of the guideline and for which a recommendation could be made without reviewing new evidence, via informal consensus based on the criteria outlined above. In these instances, the committee were also informed by other suitable evidence they were aware of, including real world evidence, for example the MBRRACE-UK reports and UK Teratology Information Service.

  This was documented as a basis for later recommendation making. See Table 1 in the appendix.
• The committee then met a second time to draft recommendations based on the above. The section “Committee’s discussion of the recommendations” documents the deliberation.

Quality assessment of sources underpinning the recommendations

Quality assessment of the evidence in evidence reviews covered by this guideline or other NICE guidelines are documented in the relevant evidence reviews, available on the NICE website for the relevant guideline. According to the Developing NICE guidelines: the manual, national legislation or national policy does not need quality assessment in the same way as other evidence, given the nature of the source.

The committee’s discussion and interpretation of the evidence

Taking the woman’s history at the first antenatal appointment is standard practice and is an essential step of assessing the woman’s needs, risk factors and planning her care. The committee agreed by consensus what issues should be asked from the woman when taking history. History taking should include her medical, obstetric and family history. The committee also agreed that the other biological parent’s family history may also be relevant. The NICE guideline on antenatal and postnatal mental health includes recommendations on asking about the woman’s mental health, particularly in relation to recognising depression, anxiety and severe mental illness so cross references to relevant sections in the guideline were made. In addition to the woman’s medical and obstetric history and family history, the committee agreed that it is important to ask her about any current or recent medications, including over-the-counter medicines, health supplements and herbal remedies. The woman’s medication gives an indication of her health and it is also important to be aware of intake of any medicines or supplements that may not be safe during pregnancy so that the woman can advised on safe use of medicine during pregnancy. The committee were aware of the resources on safe medicine use in pregnancy provided by the UK Teratology Information Service and their best use of medicines in pregnancy (bumps) information leaflets that may be useful for both healthcare professionals and women.

The committee also agreed that it is important for the maternity services to be aware of the woman’s allergies to plan safe care. Asking about her occupation is also important so that the healthcare providers can discuss how her work conditions might impact her pregnancy and vice versa. This is also an opportunity to make the woman aware of her statutory rights and the statutory duties that employers have in relation to the pregnant woman.

History taking is an opportunity to gain an understanding of the woman’s home situation and what support she has and any issues related to her partner or family members that might impact her wellbeing, such as illness or substance use problems. This will enable the maternity services to tailor their care according to the woman’s situation and needs. In some cases, this can prompt safeguarding actions.

The committee agreed that it is important to ask about behaviours such as diet, physical activity, smoking, alcohol and drug use so that the women can be advised on healthy choices. The committee agreed that the woman should also be asked about her partner’s smoking. A cross reference was made to the NICE guideline on smoking: stopping in pregnancy and after childbirth which recommends that those women (and their partners or other household members) who currently smoke or recently have stopped smoking are referred to the NHS Stop Smoking Services. Supporting women to stop smoking as soon as possible is crucial to reduce the risk of adverse outcomes for the baby. The committee were aware that maternal smoking is linked to increased risk of stillbirth, premature birth, low birth weight and other complications.

The recommendation about taking history reflects current best practice. Sometimes history taking can prompt the need to review the woman’s previous medical records, including when the woman has had previous antenatal and obstetric care in a different area or organisation. The committee agreed that if any medical concerns arise based on history taking or if the woman is taking long-term medication, referral to appropriate doctors should be made so that the woman’s care during pregnancy is planned and optimised based on her individual situation and complications can be minimised.

The committee were aware of the disproportionate maternal mortality and stillbirth rates among women and babies from some ethnic minority backgrounds and those living in deprived areas, as highlighted by the 2020 MBRRACE-UK reports on maternal mortality and perinatal mortality. For example, black women had a more than 4-fold risk of maternal death (death during pregnancy, childbirth and up to 6 weeks after birth) and Asian women a 2-fold risk of maternal death compared to white women. Also, the stillbirth rate is significantly higher in black and Asian babies compared to white babies. Maternal mortality and stillbirth are also more prevalent in those who live in the most deprived areas (compared to those in least deprived areas). The committee discussed that healthcare professionals caring for women and babies should be aware of the increased risk of mortality in these groups. The mechanisms behind these disparities are complex and likely related to wider societal issues and inequalities. Future research should explore what interventions could improve these disparities. However, in clinical practice, it is important to recognise that the increased risk may mean that improved or additional engagement or monitoring might be beneficial.

Cardiovascular disease is the leading cause of maternal mortality in the UK according to the MBRRACE-UK report published in 2019. The committee agreed that a referral for clinical assessment by a doctor (for example a GP) should be made for pregnant women whose history suggests a potentially increased risk of undiagnosed structural cardiac condition. For example, when the woman’s family history includes cardiac abnormalities or if the woman was brought up in a country with a high incidence of rheumatic fever which could cause rheumatic heart disease. The burden of rheumatic heart disease is highest in some low income countries in sub-Saharan Africa or South Asia (Watkins 2019). As mentioned, the MBRRACE-UK report also documents the disproportionate maternal mortality among women from minority ethnic backgrounds, who may come from sub-Saharan Africa or South Asia. However the committee recognised that most maternal cardiac deaths were due to ischemic heart disease or myocardial disease and not due to undiagnosed rheumatic heart disease or other heart conditions which could be readily identified via clinical assessment. While the prevalence of such conditions is low, the potentially lifesaving impact of detecting a previously undiagnosed cardiac abnormality is hugely significant and warranted healthcare professionals considering further assessment based on a woman’s history.

The committee agreed that information sharing between primary care and maternity services is important and should be discussed and agreed with the woman. Many women contact the maternity services directly without making their GP aware of the pregnancy so it is important to share information about the pregnancy with the GP. The GP might also be able to share information about the woman relevant to her care during pregnancy, including medical concerns or safeguarding issues. Furthermore, the committee agreed that it is important to keep the woman’s GP aware of any complications or concerns that may occur during pregnancy so that her continued care in the community can be optimised. The committee discussed that this might not always happen in current practice but stressed the importance of good communication between healthcare providers so that information relevant to the pregnancy is not missed and the eventual transfer of care to community care is smooth.

Domestic abuse is common, always harmful and potentially detrimental for the safety of the woman and the unborn baby. Reflecting current practice, the committee agreed that women should be asked about domestic abuse at the first antenatal appointment or another time when she is alone. If the woman is accompanied by her chosen partner at appointments, the healthcare professionals should ensure that a private one-to-one moment is organised to that this can be discussed. The committee recognised that discussing the experience of domestic abuse is not easy so the discussions should be held in a kind, sensitive manner. The committee also agreed that those providing antenatal care should ensure that throughout her antenatal care the woman has opportunities and feels safe to disclose any concerns at home, including domestic abuse. Cross references to NICE guidelines on domestic violence and abuse and pregnancy and complex social factors were made for more guidance.

The committee discussed the importance of assessing the risk of female genital mutilation (FGM), both for the pregnant woman and the unborn baby so that appropriate safeguarding can take place. In the context of this guideline, this could be relevant for the pregnant woman, or the unborn baby when there is a family history or tradition of FGM. There is a legal duty to report suspected or known FGM for under-18s. At the same time, the committee recognised the sensitive nature of this topic and acknowledged the difficulty in addressing and discussing this issue with women, including when risk assessment might be relevant and how discussions should be held. Therefore, the committee agreed that the NICE guideline would benefit from signposting to a practical guidance for healthcare professionals developed by the Department of Health and Social Care on FGM safeguarding and risk assessment which includes guidance on how to do risk assessment, how to start conversations about it and what to do if there are concerns. In committee’s experience this guidance is practical, helpful and widely used in clinical practice.

To reflect current best practice, the committee recommended that throughout the pregnancy at every antenatal appointment, the woman should be asked about health and wellbeing, if she (or her partner) have any concerns or questions or topics they would like to discuss. For example, there are many women who have experienced a traumatic birth and this may be an issue that the woman might want to discuss. All this will allow her plans and care to be continuously reassessed and any additional care needs identified.

The committee also agreed about the importance of documenting all findings and discussions, any changes to her situation, including medication in the woman’s antenatal care records and discussing all findings with the woman at the subsequent appointment. This reflects current good practice but may sometimes be inadvertently omitted so the committee agreed to highlight this in the recommendations.

Offering to measure the woman’s height and weight and calculating her body mass index (BMI) in the booking appointment is current practice and helps to plan care and assess for risk factors, for example increased risk of venous thromboembolism or pre-eclampsia associated with high BMI. It is also current practice to take a blood test to check for blood group, rhesus D status and anaemia. In relation to BMI, the committee were aware of the discussion around the appropriateness of the standard BMI cut-offs among people from Black, Asian and some other ethnic minority groups. NICE guideline on BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups addresses this issue although it excludes pregnant women.

The UK National Screening Committee recommends certain population screening programmes during pregnancy and references to these NHS screening programmes were made (HIV, syphilis, hepatitis B, sickle cell and thalassaemia, and fetal anomalies). The committee emphasised that information about the screening programmes should be provided and discussed to enable informed decision making. The women should also be made aware that she has the right to accept or decline any part of any of the screening programmes.

Part of the NHS fetal anomaly screening programme is to offer an early ultrasound scan to screen for trisomy (Down’s syndrome, Edward’s syndrome and Patau’s syndrome). The optimal time for this screening to happen is between 11+2 and 14+1 weeks’ gestation according to the NHS fetal anomaly screening programme. The committee agreed that as with current practice, it is pragmatic to coincide the early pregnancy ultrasound scan (to determine viability and gestational age and to detect multiple pregnancy) with the early screening scan. The committee agreed that the recommended weeks to offer this early pregnancy scan should be aligned with the optimal timing for the fetal trisomy screening because most women opt for the screening test. The British Medical Ultrasound Society (BMUS) offers further guidance on the method of determining gestational age.

The second ultrasound scan in the NHS fetal anomaly programme is between 18+0 to 20+6 weeks to screen for various fetal conditions, including but not restricted to heart defects, spina bifida and cleft lip. This ultrasound scan is also an opportunity to determine the location of the placenta at this stage in pregnancy. When the placenta is found to be low lying (placenta praevia) it is important to monitor this and adjust birth plans accordingly. Placenta praevia increases risk of bleeding and can prevent the baby from descending towards the cervix during labour.

A cross reference to the NICE technology appraisal guidance on routine antenatal anti-D prophylaxis for women who are rhesus D negative was made, which recommends offering anti-D prophylaxis to rhesus negative women, usually given as a single dose at 28 weeks of pregnancy. This technology appraisal should be read alongside the NICE diagnostics guideline on high-throughput non-invasive prenatal testing for fetal RHD genotype. Current practice is also to offer a blood test at this point in pregnancy including a full blood count (anaemia parameters in particular), blood group and blood antibodies.

The committee discussed the importance of providing appropriate information, support and referral when there are any unexpected findings in examinations or investigations. This guideline does not cover what the referral pathways should be like for different situations so the committee recommended referral according to local pathways.

The NICE guideline on diabetes in pregnancy offers guidance on risk assessment, testing and diagnosis of gestational diabetes. Risk assessment for gestational diabetes is relevant for all women attending antenatal care as part of their routine care so a cross reference to the guideline was made. The guideline also recommends oral glucose tolerance test to be offered to those considered to be at risk of gestational diabetes based on the risk assessment so a reference to this was also made.

The NICE guideline on hypertension in pregnancy offer guidance on risk assessment and risk reduction of pre-eclampsia so a cross reference was made. The guideline makes recommendations about how to interpret urine test results for proteinuria but does not explicitly recommend routine testing for proteinuria although it is implied. Therefore, the committee agreed that following current practice, urine testing for proteinuria should be offered at every routine face to face appointment. Monitoring blood pressure during pregnancy was covered by another review, see evidence review K for more information. The committee agreed that routine monitoring of blood pressure and proteinuria is important so that potential hypertension or pre-eclampsia can be identified and managed early to avoid potentially serious consequences.

Other evidence reviews cover recommendations on monitoring fetal growth and wellbeing. More details are provided in evidence reviews O, P and Q.

Information provision during antenatal appointments was largely covered by evidence reviews A and B, with some further recommendations based on evidence reviews C, E and J. In addition to recommendations on what information should be provided during antenatal appointments, the committee agreed to recommend giving information about screening programmes, as recommended by the UK National Screening Committee, and immunisation such as flu, pertussis and covid during pregnancy, as recommended by the UK Joint Committee on Vaccination and Immunisation. Public Health England’s Green Book gives further guidance for healthcare professionals on immunisations and references to the relevant chapters were made alongside a reference to the NICE guideline on flu vaccination. The committee were aware that NICE is currently developing a guideline on vaccine uptake in the general population. References to various other NICE guidelines were also made, including guidelines on maternal and child nutrition, vitamin D, weight management before, during and after pregnancy and postnatal care (publication planned for April 2021). In addition, the committee agreed to reference guidance on alcohol consumption during pregnancy based on the UK Chief Medical Officer’s low-risk drinking guidelines.

The committee agreed that it is good practice to give general information to pregnant women about how to reduce the risk of human-to-human infections, such as parvovirus, chicken pox, cytomegalovirus, herpes simplex virus and corona virus. Such infections are not specific to pregnancy but could cause complications for the mother or the baby. Similarly information provision about group B streptococcus can be important due its potential impact on the baby. Contrary to the 2008 NICE guideline on antenatal care where a recommendation is made about informing “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”, the committee agreed that this recommendation is no longer needed and may be unnecessarily stigmatising to young women many of whom are not at risk of having chlamydia. Rather than routinely provide information to all women under 25 years of age about this, the approach should be individualised.

Reflecting current practice, the committee agreed that in the antenatal appointments closer to birth, discussions around the woman’s birth preferences and plans should be continued, including the benefits, risks and implications of different options. The committee discussed the importance of this also in relation to the 2015 Montgomery ruling which concluded that a patient should be told about all the risks associated with particular treatment options and all alternative options available to them so that they can make an informed decision. The NICE guideline on inducing labour offers guidance on the management options of prolonged pregnancy so a cross reference was made.