Schedule of Appointments in Routine Antenatal Care

Schedule of appointments in routine antenatal care
A NICE pathway brings together all NICE guidance, quality standards and materials to support implementation on a specific topic area. The pathways are interactive and designed to be used online. This pdf version gives you a single pathway diagram and uses numbering to link the boxes in the diagram to the associated recommendations. To view the online version of this pathway visit: http://pathways.nice.org.uk/pathways/antenatal-care
Pathway last updated: 22 November 2011 Copyright NICE 2011. All rights reserved
NICEPathways Pathways
NICE Pathways
Antenatal care pathway

Copyright NICE 2011. Pathway last updated: 22 November 2011
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NICE Pathways
Healthy pregnant woman
No additional information
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 healthcare professional.
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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NICE Pathways
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.
Booking appointment and arranging screening
See Antenatal care / Booking appointment and arranging screening
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.
Give specific information on: 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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Schedule of appointments in routine antenatal care Haemoglobinopathies
NICE Pathways
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.
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 Committeeapproved 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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NICE Pathways
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
25 weeks for nulliparous women only

Measure blood pressure and test urine for proteinuria. Measure and plot symphysisfundal height.
28 weeks
Measure blood pressure and test urine for proteinuria. 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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NICE Pathways
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.
31 weeks for nulliparous women only

Review, discuss and record the results of screening tests undertaken at 28 weeks. Measure blood pressure and test urine for proteinuria. Measure and plot symphysisfundal height.
34 weeks
Review, discuss and record the results of screening tests undertaken at 28 weeks. Measure blood pressure and test urine for proteinuria. Offer a second dose of anti-D prophylaxis to women who are rhesus D-negative (see 28 weeks [See page 6])1. Measure and plot symphysisfundal height. 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
Measure blood pressure and test urine for proteinuria.

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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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NICE Pathways
Measure and plot symphysisfundal height. 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
Measure blood pressure and test urine for proteinuria. Measure and plot symphysisfundal height. Give specific information on: Options for management of prolonged pregnancy (see the induction of labour pathway).
12 40 weeks for nulliparous women only

Measure blood pressure and test urine for proteinuria. Measure and plot symphysisfundal height. 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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Schedule of appointments in routine antenatal care 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.
NICE Pathways
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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NICE Pathways
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 careful consideration 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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NICE Pathways
nice@nice.org.uk 0845 003 7780

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Schedule of Appointments in Routine Antenatal Care

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