How should I manage a woman at first contact?

At first contact, before the booking appointment:

• Identify women who:
  • May need additional care — refer to a specialist as appropriate.
  • Are taking any medication (including over-the-counter drugs). If necessary, arrange for an immediate medication review.
    • Information on use of medicines in pregnancy is available from the UK Teratology Information Service (UKTIS).
• Offer advice about vitamins and supplements in pregnancy, including folic acid and vitamin D.
  • For more information, see the section on Nutritional supplements.
• Offer advice about lifestyle factors that may affect the pregnancy, including:
  • Diet including how to reduce the risk of a food-acquired infection.
  • Smoking, alcohol consumption, and recreational drug use.
• Advise the woman that if she wishes, her partner is welcome to attend antenatal appointments and classes with her for support.
• Provide information on sources of support and patient resources.

How should I manage a woman at the booking appointment?

• Take a history asking about:
  • General health and wellbeing including nutrition and diet, physical activity, smoking, alcohol consumption, and recreational drug use.
  • Obstetric history.
  • The medical and family history of both biological parents.
  • Previous or current mental health concerns such as depression, anxiety, severe mental illness, psychological trauma, or psychiatric treatment
    • If there are any mental health concerns, discuss with/refer to an appropriate specialist. For more information, see the CKS topic on Depression – antenatal and postnatal.
  • Current and recent medicines (including over-the-counter medicines, health supplements, and herbal remedies) and allergies.
    • Discuss safe use of medicines during pregnancy.
  • Occupation — discuss any risks and concerns.
    • For more information, see the section on work during pregnancy.
  • Her family and home situation including:
    • Available support network including other people who may be involved in the care of the baby.
    • Health or other issues affecting her partner or family members that may be significant for her health and wellbeing.
    • Domestic abuse, if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
    • Contact details for her partner and her next of kin.
  • Any concerns that the woman (and her partner, if present) would like to discuss.
    • See also the section on Managing common minor ailments.
• Assess the woman for risk of gestational diabetes:
  • Arrange testing for gestational diabetes for women with any of the following:
    • Body mass index (BMI) above 30 kg/m².
    • Previous macrosomic baby weighing 4.5 kg or more.
    • Previous gestational diabetes.
    • Family history of diabetes (first degree relative with diabetes).
    • An ethnicity with a high prevalence of diabetes.
  • Consider further testing to exclude gestational diabetes in women who have:
    • Glycosuria of 2+ or above on 1 occasion.
    • Glycosuria of 1+ or above on 2 or more occasions.
  • Women diagnosed with gestational diabetes should be offered review with the joint diabetes and antenatal clinic within 1 week.
• Assess the woman for risk of pre-eclampsia.
  • Assess the woman's risk factors for pre-eclampsia.
  • Women at risk of pre-eclampsia should be referred for consultant-led care at booking and advised on taking aspirin.
  • For information on how to manage women at risk of pre-eclampsia and women who have hypertension (with or without proteinuria), see the CKS topic on Hypertension in pregnancy.
• Assess for risk of fetal growth restriction.
  • Consider using guidance from the Royal College of Obstetricians and Gynaecologists Small-for-gestational-age fetus, investigation and management and the NHS Saving babies' lives care bundle version 2 which provide detailed information on risk factors, screening, diagnosis, and management of fetal growth restriction.
• Assess for risk of venous thromboembolism (VTE) at the booking appointment, and after any hospital admission or significant health event during pregnancy.
  • Risk factors include previous VTE, thrombophilia, medical comorbidities such as cancer, heart failure; active systemic lupus erythematosus, inflammatory polyarthropathy or inflammatory bowel disease; nephrotic syndrome; type 1 diabetes mellitus with nephropathy; sickle cell disease; current intravenous drug user, obesity, older age, and smoking.
  • Pregnant women at risk of VTE should be referred to an obstetrician for further assessment and discussion on management.
  • For detailed information see guidance from the Royal College of Obstetricians and Gynaecologists Reducing the risk of venous thromboembolism during pregnancy and the puerperium.
• Assess the woman's risk of and, if appropriate, discuss female genital mutilation (FGM) in a kind, sensitive manner.
  • Take appropriate action about risks of FGM in line with UK government guidance on Safeguarding women and girls at risk of FGM. 
• Offer examination and investigations including:
  • Measuring height and weight to calculate BMI.
    • For anyone with a BMI of over 30 kg/m², offer testing for gestational diabetes. 
    • For anyone with a BMI of over 40 kg/m², discuss the option for referral to a specialist obesity service or a specialist practitioner for tailored advice and support during the pregnancy.
  • Blood pressure and urine dipstick testing to check for proteinuria.
    • For detailed information on how to manage women who have hypertension with or without proteinuria, including indications for urgent referral, see the CKS topic on Hypertension in pregnancy.
  • Blood tests including full blood count, blood group, and rhesus D status.
• If there are any medical concerns or review of long-term medicines is needed, refer to/discuss with an obstetrician.
• Discuss screening programmes in pregnancy including risks, benefits, and limitations — advise the woman that she can accept or decline any part of any of the screening programmes offered. Offer screening for:
  • Infectious diseases in pregnancy including HIV, syphilis, and hepatitis B.
    • Patient information on the NHS infectious diseases in pregnancy screening programme is available from Public Health England. 
  • Sickle cell and thalassaemia.
    • Patient information on the NHS sickle cell and thalassaemia screening programme is available from Public Health England.
  • Fetal anomalies.
    • Patient information Screening tests for you and your baby is available from Public Health England. 
• Discuss changes during pregnancy, including:
  • How the baby develops and what to expect at each stage of the pregnancy.
  • Physical, emotional, and relationship changes.
  • Support between partners.
• Discuss staying healthy during pregnancy including:
  • Immunization for flu, whooping cough, and other infections such as respiratory syncytial virus (RSV)
    • For more information, see the CKS topics on Immunizations - seasonal influenza and the Public Health England Green Book on immunisation against infectious disease.
  • Infections that can impact on the baby in pregnancy or during birth (such as group B 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.
• Discuss how to contact the:
  • Midwifery team, for non-urgent advice.
  • Maternity service, for urgent concerns such as pain and bleeding.
• Provide information on resources and support for expectant and new parents including details of locally available antenatal classes and breastfeeding workshops.
• 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. 

How should I manage a woman at her 16 week appointment?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Measure blood pressure and carry out a urine dipstick test for proteinuria.
• Re-assess the risk of pre-eclampsia.
  • Women at risk of pre-eclampsia should be under the care of a consultant obstetrician and advised on taking aspirin. For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
  • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
• Reassess the risk of fetal growth restriction, if the woman agrees.
• Reassess the plan of care for the pregnancy and consider if additional care is needed.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.
• Discuss and give information on:
  • Physical, emotional, and relationship changes.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
• Start discussing with the woman: 
  • Her birth preferences (including place and mode of birth) and the implications, benefits, and risks of these.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways and provide appropriate information and support.
• Update the woman’s antenatal records with details of history, test results, examination findings, medicines, and discussions.

How should I manage a nulliparous woman at her 25 week appointment?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Repeat examinations and investigations including:
  • Checking blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • Symphysis–fundal height is the distance from the lowest part of the uterus (near the pubic bone) to the highest part of the uterus, measured with a non-elastic tape measure. 
    • Detailed information on how to measure and record fetal growth using the symphysis–fundal height is given on the website of the Perinatal Institute, along with examples of fetal growth charts. 
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
• Discuss the baby’s movements with the woman and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Continue discussion on: 
  • Her birth preferences (including place and mode of birth) and the implications, benefits, and risks of these.
  • Physical, emotional, and relationship changes.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways and provide appropriate information and support.
• Update the woman’s antenatal records with details of history, test results, examination findings, medicines, and discussions. 
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

How should I manage a woman at 28 weeks?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression – antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Offer examination and investigations including:
  • Measuring blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
  • A blood test to check full blood count, blood group, and antibodies.
• Offer anti-D prophylaxis to rhesus-negative women.
• Discuss the baby’s movements with the woman and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Advise the woman to avoid going to sleep on their back after 28 weeks of pregnancy and to consider using pillows, for example, to maintain their position while sleeping.
  • Explain that there may be a link between going to sleep on one’s back and stillbirth in late pregnancy (after 28 weeks).
• Discuss and give information on:
  • Preparing for labour and birth, including information about coping in labour and creating a birth plan.
  • Recognizing active labour.
  • The postnatal period, including:
    • Caring for the new baby and feeding them.
    • Vitamin K prophylaxis.
    • Newborn screening.
    • Postnatal self-care (including pelvic floor exercises).
    • Awareness of mood changes and postnatal mental health.
• Continue discussion on:
  • Physical, emotional, and relationship changes.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways and provide appropriate information and support.
• Update the woman’s antenatal records with details of history, test results, examination findings, medicines, and discussions.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

How should I manage a nulliparous woman at 31 weeks?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Discuss the baby’s movements and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Offer examination and investigations including:
  • Measuring blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
• Continue discussion on:
  • Physical, emotional, and relationship changes.
  • Sleep position.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
  • Preparing for labour and birth, including information about recognizing active labour, coping in labour, and creating a birth plan — confirm birth preferences.
  • The postnatal period.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways and provide appropriate information and support.
• Reassess the plan of care for the pregnancy and update the woman’s antenatal record with details of history, test results, examination findings, medicines, and discussions.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

How should I manage a woman at 34 weeks?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Discuss the baby’s movements and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Offer examination and investigations including:
  • Measuring blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
• If following a two-dose regimen of antenatal anti-D prophylaxis offer the second dose to women who are rhesus D-negative.
• Continue discussion on:
  • Physical, emotional, and relationship changes.
  • Sleep position.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
  • Preparing for labour and birth, including information about recognizing active labour, coping in labour, and creating a birth plan — confirm birth preferences.
  • The postnatal period.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways, and provide appropriate information and support.
• Reassess the plan of care for the pregnancy and update the woman’s antenatal record with details of history, test results, examination findings, medicines, and discussions.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

How should I manage a woman at 36 weeks?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Discuss the baby’s movements and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Offer examination and investigations including:
  • Measuring blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
  • Abdominal palpation to check the position of the baby.
    • If breech presentation is suspected on abdominal palpation, offer an ultrasound scan to determine the presentation.
    • For more information, see the section on Breech presentation.
• Continue discussion on:
  • Physical, emotional, and relationship changes.
  • Sleep position.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
  • Preparing for labour and birth, including information about recognizing active labour, coping in labour, and creating a birth plan — confirm birth preferences.
  • The postnatal period.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways, and provide appropriate information and support.
• Reassess the plan of care for the pregnancy and update the woman’s antenatal record with details of history, test results, examination findings, medicines, and discussions.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

How should I manage a woman at 38 weeks?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Discuss the baby’s movements and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Offer examination and investigations including:
  • Measuring blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
  • Abdominal palpation to check the position of the baby.
    • If breech presentation is suspected on abdominal palpation, offer an ultrasound scan to determine the presentation.
    • For more information, see the section on Breech presentation.
• Discuss prolonged pregnancy and options on how to manage this. Give the woman specific information on:
  • The risks associated with pregnancies that last longer than 42 weeks.
  • Options for management of prolonged pregnancy, such as a membrane sweep, induction of labour between 41+0 and 42+0 weeks, and expectant management. This may vary according to local protocols.
  • For more information, see the National Institute for Health and Care Excellence (NICE) guidance on Inducing Labour.
• Continue discussion on:
  • Physical, emotional, and relationship changes.
  • Sleep position.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
  • Preparing for labour and birth, including information about recognizing active labour, coping in labour, and creating a birth plan — confirm birth preferences.
  • The postnatal period.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways, and provide appropriate information and support.
• Reassess the plan of care for the pregnancy and update the woman’s antenatal record with details of history, test results, examination findings, medicines, and discussions.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

How should I manage a nulliparous woman at 40 weeks?

• Update the history, asking about: 
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Discuss the baby’s movements and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Offer examination and investigations including:
  • Measuring blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
  • Abdominal palpation to check the position of the baby.
    • If breech presentation is suspected on abdominal palpation, offer an ultrasound scan to determine the presentation.
    • For more information, see the section on Breech presentation.
• Discuss prolonged pregnancy and options on how to manage this. Give the woman specific information on:
  • The risks associated with pregnancies that last longer than 42 weeks.
  • Options for management of prolonged pregnancy, such as a membrane sweep, induction of labour between 41+0 and 42+0 weeks, and expectant management. This may vary according to local protocols.
  • For more information, see the National Institute for Health and Care Excellence (NICE) guidance on Inducing Labour.
• Continue discussion on: 
  • Physical, emotional, and relationship changes.
  • Sleep position.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
  • Preparing for labour and birth, including information about recognizing active labour, coping in labour, and creating a birth plan — confirm birth preferences.
  • The postnatal period.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways, and provide appropriate information and support.
• Reassess the plan of care for the pregnancy and update the woman’s antenatal record with details of history, test results, examination findings, medicines, and discussions.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

How should I manage a woman with an uncomplicated pregnancy after 41 weeks?

• Update the history, asking about:
  • General health and wellbeing.
    • If the woman has had any hospital admission or significant health event since her last appointment, assess her risk of venous thromboembolism.
  • Medications (including over-the-counter medicines, health supplements, and herbal remedies).
  • Mental health — if there are any concerns, discuss with/refer to an appropriate specialist.
    • For more information, see the CKS topic on Depression - antenatal and postnatal.
  • Domestic abuse if she is alone. If not alone, ensure that there is an opportunity to have a private, one-to-one discussion at the earliest opportunity.
  • Any other concerns she (and her partner, if present) would like to discuss.
    • For more information, see the section on Managing common minor ailments.
• Discuss the baby’s movements and ask if she has any concerns.
  • If there are any concerns, assess her and the baby, referring to secondary care where appropriate.
  • Advise the woman to contact maternity services at any time of day or night if she has any concerns about her baby's movements or she notices reduced fetal movements.
• Offer examination and investigations including:
  • Measuring blood pressure and testing for proteinuria to screen for hypertension and possible pre-eclampsia.
    • For information on how to manage women who are at risk of pre-eclampsia or who have hypertension with or without proteinuria, see the CKS topic on Hypertension in pregnancy.
    • Warn the woman about the symptoms of pre-eclampsia and advise her to seek immediate advice if she develops any symptoms (including during the postpartum period).
  • Measure and plot symphysis–fundal height (to identify small- or large-for-gestational-age infants).
    • If there are concerns that the symphysis–fundal height is large for gestational age consider an ultrasound scan for fetal growth and wellbeing.
    • If there are concerns that the symphysis–fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.
  • Abdominal palpation to check the position of the baby.
    • If breech presentation is suspected on abdominal palpation, offer an ultrasound scan to determine the presentation.
    • For more information, see the section on Breech presentation.
• Discuss prolonged pregnancy and options on how to manage this. Give the woman specific information on:
  • The risks associated with pregnancies that last longer than 42 weeks.
  • Options for management of prolonged pregnancy, such as a membrane sweep, induction of labour between 41+0 and 42+0 weeks, and expectant management. This may vary according to local protocols.
  • For more information, see the National Institute for Health and Care Excellence (NICE) guidance on Inducing Labour.
• Continue discussion on:
  • Physical, emotional, and relationship changes.
  • Sleep position.
  • Support between partners.
  • Resources for expectant and new parents.
  • Bonding with the baby and emotional attachment.
  • Preparing for labour and birth, including information about recognizing active labour, coping in labour, and creating a birth plan — confirm birth preferences.
  • The postnatal period.
• Ensure results of any blood or screening tests from previous appointments have been reviewed, recorded, and discussed with the woman.
  • If there are any unexpected results from examinations or investigations, offer referral according to local pathways, and provide appropriate information and support.
• Reassess the plan of care for the pregnancy and update the woman’s antenatal record with details of history, test results, examination findings, medicines, and discussions.
  • Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social, and emotional needs.

Pre-eclampsia

• Advise all pregnant women to seek immediate medical review if they experience symptoms of pre-eclampsia (including during the first 4 weeks postpartum), such as:
  • Severe headache.
  • Problems with vision, such as blurred vision, flashing lights, double vision, or floating spots.
  • Severe pain below the ribs.
  • Vomiting.
  • Breathlessness.
  • Sudden swelling of the face, hands, or feet.
• Risk factors for pre-eclampsia include:
  • Previous history of pre-eclampsia or hypertension in pregnancy.
  • Pre-existing renal disease.
  • Autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome.
  • Type 1 or type 2 diabetes.
  • Pre-existing vascular disease, such as hypertension.
  • Nulliparity.
  • Age 40 years or older.
  • Pregnancy interval of more than 10 years.
  • Body mass index 35 kg/m² or above.
  • Multiple pregnancy.
  • Family history of pre-eclampsia.
• Emergency assessment in secondary care should be arranged for any woman in whom pre-eclampsia is suspected.

Basis for recommendation

The information on managing pregnant women at each antenatal appointment is largely based on expert opinion from the National Institute of Health and Care Excellence (NICE) in Antenatal care [NICE, 2021a] and Schedule of antenatal appointments [NICE, 2021c], the World Health Organization (WHO) Recommendations on antenatal care for a positive pregnancy experience [WHO, 2017], review articles [BMJ Best Practice, 2019; Caro, 2020], and a Public Health Agency publication The pregnancy book [PHA, 2021].

Recommended routine antenatal appointments

The information on routine antenatal appointments is based on the NICE guideline Antenatal care [NICE, 2021a] and Schedule of antenatal appointments [NICE, 2021c].

The statement that women and babies from some minority ethnic backgrounds and those who live in deprived areas have an increased risk of death and may need closer monitoring and additional support is based on the NICE guideline Antenatal care [NICE, 2021a] which references the 2020 MBRRACE-UK reports on maternal and perinatal mortality. The reports showed that:

• Compared with white women (8/100,000), the risk of maternal death during pregnancy and up to 6 weeks after birth is:
  • 4 times higher in black women (34/100,000).
  • 3 times higher in women with mixed ethnic background (25/100,000).
  • 2 times higher in Asian women (15/100,000; does not include Chinese women).
• Compared with white babies (34/10,000), the stillbirth rate is:
  • More than twice as high in black babies (74/10,000).
  • Around 50% higher in Asian babies (53/10,000).
• Women living in the most deprived areas (15/100,000) are more than 2.5 times more likely to die than women living in the least deprived areas (6/100,000).
• The stillbirth rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many stillbirths for women living in the most deprived areas (47/10,000) compared with the least deprived areas (26/10,000).

Assessment for risk of venous thromboembolism (VTE)

Recommendations on assessment for risk of VTE are based on clinical guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) Reducing the risk of venous thromboembolism during pregnancy and the puerperium. Green-top Guideline No 37a [RCOG, 2015a] and NICE Antenatal care [NICE, 2021a].

Assessment for risk of gestational diabetes

Recommendations on assessment for risk of gestational diabetes are based on clinical guidance from NICE Diabetes in pregnancy: management from preconception to the postnatal period (NG3) [NICE, 2015].

Assessment for risk of pre-eclampsia

Recommendations on assessment for risk of pre-eclampsia are based on clinical guidance from NICE Hypertension in pregnancy: diagnosis and management [NICE, 2019b].

• Pregnant women identified at the booking appointment as at increased risk of pre-eclampsia should be assessed in secondary care by a specialist. Aspirin prophylaxis, unless contraindicated, reduces the occurrence of pre-eclampsia, preterm birth, and fetal and neonatal mortality in women at increased risk of developing the condition (if they have one high risk factor or more than one moderate risk factor for pre-eclampsia). [NICE, 2019a].

Assessment for risk of fetal growth restriction

The recommendation on assessment for risk of fetal growth restriction is based on clinical guidance from NICE Antenatal care [NICE, 2021a].

Assessment for risk of female genital mutilation (FGM)

The recommendations on assessment for risk of FGM is based on clinical guidance from NICE Antenatal care [NICE, 2021a] and the RCOG Female genital mutilation and its management green-top guideline No. 53 [RCOG, 2015b].

• All women, irrespective of country of origin, should be asked for a history of FGM at their booking antenatal visit so that FGM can be identified early in the pregnancy. This should be documented in the maternity record [RCOG, 2015b].
• Women with FGM are more likely to have obstetric complications and consultant-led care is generally recommended. However, some women with previous uncomplicated vaginal deliveries may be suitable for midwifery-led care in labour [RCOG, 2015b].

Immunization for flu, whooping cough, and other infections 

The recommendations on immunization are based on the NICE guidance Antenatal care [NICE, 2021a], Public Health England Immunisations against infectious disease (The Green book) [PHE, 2021a], the Public Health England guidance Pertussis (whooping cough) vaccination programme for pregnant women: information for healthcare practitioners [PHE, 2021b].

• Influenza — pregnant women should be offered inactivated influenza vaccine as the risk of serious illness from influenza is higher in pregnant women. Inactivated influenza vaccines are preferred for those who are pregnant [PHE, 2021a].
• Pertussis — although it is recommended that women are offered the vaccine between weeks 16–32 of pregnancy, women may still be immunized after week 32 of pregnancy until delivery. However, this may not offer as high a level of passive protection to the baby, particularly if they are born pre-term. Offering the vaccine from week 16 of pregnancy gives pregnant women greater opportunity to take up the offer of vaccination and will offer some protection to infants born prematurely who may be particularly vulnerable to complications from pertussis [PHE, 2021b].

Assessing mental health in pregnancy

The recommendation on screening for mental health conditions in pregnancy is based on clinical guidance from NICE Antenatal care [NICE, 2021a] and Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2020].

Examination and investigations during antenatal appointments

Recommendations are based on clinical guidance from NICE Antenatal care [NICE, 2021a] and PHE Infectious diseases in pregnancy screening: clinical guidance [PHE, 2016 (updated 2021)], Sickle cell and thalassaemia (SCT) screening [PHE, 2013a], and NHS Fetal Anomaly Screening Programme [PHE, 2013b].

• Offering to measure the woman’s height and weight and calculating her body mass index (BMI) during 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 [NICE, 2021a].
• Identifying the woman's blood group is recommended in case transfusion is required in pregnancy or at delivery [NICE, 2021a].
• Screening for rhesus D status at booking and at the 28 week appointment is recommended because rhesus D-negative women should be offered appropriate antenatal and postnatal immunoprophylaxis, with the aim of preventing rhesus D alloimmunization in subsequent pregnancies [NICE, 2019c; NICE, 2021a].
• The UK National Screening Committee recommends certain population screening programmes during pregnancy including HIV, syphilis, hepatitis B, sickle cell and thalassaemia, and fetal anomalies. The NICE guideline committee emphasise that information about the screening programmes should be provided and discussed to enable informed decision-making — women should be made aware that they have the right to accept or decline any part of any of the screening programmes [NICE, 2021a].
• The recommendation to use symphysis–fundal height (SFH) to identify large- or small-for-gestational-age babies is based on expert opinion from the NICE guideline development group. NICE states that although the evidence suggested that SFH measurement is not very sensitive, it is easily performed with little resource implications and essentially no adverse effects. If SFH measurement was not done routinely, it would make the selective choice of who should receive an ultrasound scan more challenging. Therefore the committee agreed, it was appropriate to offer SFH measurement at each antenatal appointment after 24+0 weeks unless the woman is already undergoing regular growth scans [NICE, 2021a].
• The description of how to measure SFH is based on published expert opinion from the NHS Perinatal Institute. 

Fetal movements

The recommendations on monitoring fetal movements and further assessment where there are concerns are based on clinical guidance from NICE guideline Antenatal care [NICE, 2021a].

• The NICE guideline advises service providers to recognize that use of structured fetal movement awareness packages, such as the one studied in the AFFIRM trial, have not been shown to reduce stillbirth rates [NICE, 2021a].

Antenatal anti-D prophylaxis

The NICE technology appraisal guidance on Routine antenatal anti-D prophylaxis (RAADP) [NICE, 2019c] states that RAADP can be given as two doses of anti-D immunoglobulin of 500 IU (one at 28 weeks and one at 34 weeks gestation), as two doses of anti-D immunoglobulin of 1000–1650 IU (one at 28 weeks and one at 34 weeks gestation), or as a single dose of 1500 IU either at 28 weeks or between 28 and 30 weeks gestation. RAADP is not used uniformly throughout the NHS. In 2005, a survey of obstetric units reported that 75% offered RAADP, and of these 81% used one of the two-dose regimens. RAADP is usually administered by community midwives or at antenatal clinics. 

Pre-eclampsia

The information on pre-eclampsia is based on the NICE clinical guideline Hypertension in pregnancy: diagnosis and management [NICE, 2019b].

What dietary advice should I offer?

• Discuss the importance of healthy eating with anyone who is pregnant. Ask people about their usual dietary habits and preferences, and discuss the following:
  • The benefits of healthy foods and drinks, as well as healthy dietary habits, for them, baby and the wider family.
  • Foods and drinks that should be encouraged and avoided during pregnancy. 
  • Healthy food and drink options that are acceptable and available for the person.
  • Myths about what and how much to eat during pregnancy.
    • Reassure people that they do not need to 'eat for two' and, other than avoiding specific foods and drinks, they do not need a special diet during pregnancy, but it is important to eat a variety of different foods every day to get the right balance of nutrients for them and their baby. 
• Advise the woman to eat a variety of foods, including:
  • Fruit and vegetables (at least 5 portions each day).
  • Carbohydrates, such as bread, pasta, rice, and potatoes.
  • Protein, such as lean meat, fish, beans, and lentils.
  • Foods rich in fibre, such as wholegrain breads, fruits, and vegetables.
  • Dairy foods, such as milk, yoghurt, and cheese.
• Advise the woman to eat foods rich in:
  • Folic acid such as green leafy vegetables, fortified breakfast cereals, and brown rice.
  • Vitamin D such as oily fish, eggs, fortified breakfast cereals, and fortified margarine.
• Discuss the Healthy Start Scheme — see the section on Healthy start for more information.
• Advise the woman that peanuts may be eaten during pregnancy (unless allergic to them).
  • Previous advice from the Department of Health advised that pregnant women may wish to avoid eating peanuts during pregnancy. This advice has now changed because there is no clear evidence that peanuts affect the chance of the unborn baby developing a peanut allergy.
• Advise the woman to avoid foods that may put her or her fetus at risk, including:
  • Foods that may contain Listeria such as soft mould-ripened cheeses (Camembert, brie, and blue-veined cheese), unpasteurized milk or cheese, and pate (including vegetable pate).
    • Listeria infection in pregnancy can lead to miscarriage, stillbirth, or severe illness in the newborn baby.
  • Foods that may contain Salmonella such as uncooked or undercooked ready-prepared meals, uncooked or cured meat (including salami), and raw shellfish such as oysters.
    • Eggs produced under the British Lion Code of Practice (stamped with the red lion) are thought to be very low risk for salmonella if eaten raw or partially cooked.
  • Liver and liver products as these may contain high levels of vitamin A.
    • Ingesting too much vitamin A in pregnancy can increase the risk of birth defects in the baby.
    • Multivitamin supplements, fish liver oil supplements, or any other supplements containing vitamin A should be avoided in pregnancy.
  • Fish containing relatively high levels of methylmercury, such as shark, swordfish, and marlin.
    • Exposure to high levels of methylmercury in the womb can affect the nervous system of the fetus, potentially increasing the risk of learning or behavioural problems.
    • Consumption of tuna should be limited to no more than four medium-sized cans or two fresh tuna steaks per week as tuna may contain high levels of mercury.
• Advise the woman on limiting caffeine intake:
  • Caffeine intake should be limited to less than 200 mg a day as high levels of caffeine have been associated with low birth weight in the baby.
  • Caffeine is present in coffee, tea, chocolate, and colas. The amount of caffeine in food and drink varies, but as a guide:
    • One mug of instant coffee contains 100 mg of caffeine.
    • One mug of filter coffee contains 140 mg of caffeine.
    • One mug of tea contains 75 mg of caffeine.
    • One can of cola contains up to 40 mg of caffeine.
    • One can of 'energy' drink contains up to 80 mg of caffeine.
    • One bar of plain chocolate contains up to 50 mg of caffeine — the caffeine content of milk chocolate is about half that of plain chocolate.
• Detailed patient information on diet during pregnancy is available from:
  • The Royal College of Obstetricians and Gynaecologists — Healthy eating and vitamin supplements in pregnancy. 
  • The NHS — Healthy Start, Keeping well in pregnancy, and Start4life. 
  • Public Health Agency (Northern Ireland) – The pregnancy book. 
  • NHS Inform – Ready steady baby. 

What advice should I give about nutritional supplements?

Offer advice about vitamins and supplements in pregnancy:

• Folic acid
  • Advise the woman to take folic acid (400 micrograms per day) throughout the first 12 weeks of pregnancy (if she is not already doing so). This is to reduce the risk of neural tube defects in the baby.
    • Reassure anyone with a body mass index (BMI) of 25 kg/m² or more who is planning to become pregnant or is in the first 12 weeks of pregnancy that they do not need to take more than 400 micrograms of folic acid a day unless they have an increased risk of having a baby with a neural tube defect or other congenital malformation.
  • A higher daily dose (5 mg of folic acid a day) is recommended for women at a higher risk of conceiving a child with a neural tube defect including women who have previously had an infant with a neural tube defect, those taking certain antiepileptic medications, and women with diabetes, coeliac disease, sickle-cell disease, or thalassaemia.
• Vitamin D
  • Advise the woman to take a vitamin D supplement (10 micrograms of vitamin D per day) throughout pregnancy.
  • This is particularly important for women with darker skin, such as those of African, Afro–Caribbean, or South Asian family origin; those who have limited exposure to sunlight, such as those who are housebound or confined indoors for long periods; who cover their skin for cultural reasons.
• Healthy Start vitamins (containing folic acid, ascorbic acid, and vitamin D) are available for pregnant women through the Healthy Start scheme.
  • For further information, see the section on Healthy Start.
• Advise the woman to:
  • Avoid vitamin A supplementation — high levels may be teratogenic.

What advice can I give about exercise during pregnancy?

• Discuss the importance of physical activity with anyone who is pregnant.
• Ask people about their usual physical activity and exercise habits and preferences
• Where appropriate, provide information on:  
  • How to safely continue with physical activity.
  • How to gradually increase physical activity during pregnancy if they are not already physically active.
  • The importance of minimising sedentary time, such as sitting for long periods.
• Advise the person:
  • That moderate exercise may be continued or started during pregnancy.
    • Exercise choices should reflect activity levels pre-pregnancy and should include strength training.
    • Vigorous activity is not recommended for previously inactive women.
  • To avoid:
    • Sports that may cause abdominal trauma such as contact sports, high impact sports, and falls.
    • Scuba diving as it has been associated with an increased risk of birth defects and fetal decompression disease.

What advice can I give regarding use of medicines and complementary therapies during pregnancy?

• Advise the woman to check with her GP or pharmacist before taking any over-the-counter medicines.
  • Few medicines have been established as being safe to use in pregnancy, and the potential risks and benefits of use for both mother and baby should therefore be weighed up.
  • Paracetamol is generally considered to be safe to use during pregnancy. Pregnant women are advised to use the lowest dose of paracetamol that works, only for as long as needed.
• Few complementary therapies have been established as being safe during pregnancy.
  • Herbal medicines should not be thought of as safe alternatives to conventional medicines during pregnancy as constituents may be toxic, have pharmacological activity, or be contaminated.
• Patient information leaflets on use of medicines in pregnancy (produced by the UK Teratology Information Service) are available on the bumps (best use of medicines in pregnancy) website.

What advice can I give regarding alcohol, smoking, and recreational drugs during pregnancy?

• Alcohol
  • At the first antenatal (booking) appointment, and later if appropriate, discuss alcohol consumption. Explain that:
    • There is no known safe level of alcohol consumption during pregnancy.
    • Drinking alcohol during the pregnancy can lead to long-term harm to the baby.
    • The safest approach is to avoid alcohol altogether to minimize risks to the baby.
  • See the CKS topic on Alcohol - problem drinking for more information, if needed.
• Smoking
  • If the woman or her partner smokes or has stopped smoking within the past 2 weeks, offer a referral to NHS Stop Smoking Services.
  • For more detailed information, see the CKS topic on Smoking cessation.
• Recreational drugs
  • Advise the woman that use of recreational drugs (such as cannabis, ecstasy, cocaine, and heroin) can harm their baby.
  • Explain the importance of talking to their doctor or midwife about recreational drug use so that advice and support can be provided.
    • Be aware that the woman may have other concerns, such as fear of professional attitudes, and the potential role of social services.
  • Offer referral to an appropriate substance misuse service, where indicated.
    • Explain that additional treatments may be needed to help dependent drug users stabilize or come off drugs initially.
    • A named midwife or doctor who has specialized knowledge of, and experience in, the care of women who misuse substances should be involved — ensure the woman knows how to contact them.
    • Care should be co-ordinated by a multidisciplinary team including obstetric departments, GPs, drug specialists, and social services.

What advice can I give regarding sexual intercourse during pregnancy?

Reassure the woman that intercourse is thought to be safe during an uncomplicated pregnancy.

What advice can I give on how to avoid toxoplasmosis?

• Toxoplasmosis is an infection with the parasite Toxoplasma gondii.
  • If acquired during pregnancy, toxoplasmosis can cause stillbirth, miscarriage, intracranial anomalies, visual impairment, and developmental delay.
• The toxoplasmosis parasite can be acquired by:
  • Eating undercooked or uncooked meat (such as salami).
  • Eating unwashed fruit or vegetables which may be contaminated by cat faeces.
  • Accidental ingestion after handling cat litter faeces.
  • Contact with lambs or sheep.
  • Mother-to-child transmission. This occurs when primary infection occurs during pregnancy (congenital toxoplasmosis).
• To reduce the risk of toxoplasmosis infection, advise the woman to:
  • Wash her hands before handling food.
  • Thoroughly wash all fruit and vegetables, including ready-prepared salads, before eating.
  • Thoroughly cook raw meats and ready-prepared chilled meals.
  • Wear gloves and thoroughly wash hands after handling soil and gardening.
  • Avoid cat faeces in cat litter or in soil.
  • Avoid lambing or milking ewes and contact with newborn lambs.

What advice can I give regarding travel during pregnancy?

• Air travel — advise the woman that:
  • There is no evidence that air travel is harmful for healthy women with an uncomplicated pregnancy. Pregnant women with certain underlying medical conditions and those who have developed a complication during pregnancy may be advised not to fly.
  • Airlines may ask for a letter from a midwife or doctor after 27 weeks' gestation confirming the expected date of delivery and that the pregnancy is uncomplicated. Most airlines do not allow women to fly after 37 weeks.
  • Risk of developing a deep vein thrombosis (DVT) is increased while flying (due to sitting for prolonged lengths of time).
    • Risk is higher with longer flights and increases further if the woman has additional risk factors for DVT (such as a previous DVT or being overweight).
    • Individual risk should be discussed with a midwife or doctor — women with additional risk factors for DVT may be advised to have heparin injections regardless of flight duration.
    • Patient information including measures to reduce the risk of DVT Airtravel and pregnancy is available from the Royal College of Obstetricians and Gynaecologists.
• Car travel
  • Advise the woman to always wear her seatbelt with the diagonal strap across her body between her breasts and with the lap belt over her upper thighs. The straps should lie above and below the bump, and not over it.
• Travelling abroad 
  • Advise the woman that if she is travelling abroad, she should ensure that she has:
    • Access to medical help if required.
    • Had any appropriate immunizations.
    • Adequate travel insurance.
    • A UK Global Health Insurance Card (GHIC) which will allow her to get state healthcare in Europe at a reduced cost (or sometimes for free). This does not replace travel insurance.
  • Advise the woman that travel to some destinations, including those with Zika and malaria risk, is not advised during pregnancy and should be avoided if possible.
    • Pregnant women are at greater risk of severe or fatal malaria. Malaria infection in pregnancy also increases the risk of serious complications including premature birth, miscarriage, and stillbirth. For more information, see the CKS topics on Malaria and Malaria prophylaxis, and the patient information leaflets from the UK teratology Service Malaria and Public Health England Malaria: information for people travelling overseas.
    • Zika infection in pregnant women can cause serious birth defects including microcephaly. For further information see guidance from Public Health England Zika virus: travel advice and the TravelHealthPro website, and patient information from the UK Teratology Information Service Zika virus infection in pregnancy.

What is the Healthy Start Scheme?

• The Healthy Start Scheme is a government scheme that aims to improve the health of pregnant women and families with children aged under 4 years. It is available in England, Wales, and Northern Ireland and provides:
  • Free vouchers or payments every 4 weeks that can be spent on cow’s milk, fresh, frozen, or tinned fruit and vegetables, infant formula milk, and fresh, dried, and tinned pulses.
  • Free Healthy Start vitamins.
• To apply for the Healthy Start scheme, a paper application form can be downloaded from the Healthy Start website, or requested from a GP or Midwife. Alternatively, requests can be made via the Healthy Start helpline on 0345 607 6823.
  • For information (including eligibility) see the Healthy start website.
• In Scotland the Healthy Start Scheme is not available — pregnant women and families with a child under the age of 3 years can apply for Best Start Foods instead.
  • Best Start Foods is a prepaid card that can be used in shops or online to buy healthy foods like milk or fruit by pregnant women and families with a child under the age of 3 years.
  • For information see the Scottish Government website Best Start Foods. 

What advice should I give about working and maternity benefits?

• Advise that most women can continue working during pregnancy.
  • Employers are required to assess risks which might be posed to the health and safety of pregnant women.
  • If a significant risk is identified, steps to avoid the risk should be taken, such as:
    • Adjusting working conditions or hours to remove the risk. If this is not possible, suitable alternative work on the same terms and conditions should be given. If this is not possible, suspension on paid leave should be arranged for as long as necessary to protect the health and safety of her and her child.
  • Examples of occupations where it is not advisable for the woman to continue working include occupations that require scuba diving and working with hazardous substances such as lead.
  • For more detailed information and advice, see the:
    • Health and Safety Executive website.
    • Royal College of Occupational Physicians website.
• Advise the woman about her employment rights.
  • Pregnant women have a right to:
    • Paid time off for antenatal care — this is not just for medical appointments, it can also include antenatal or parenting classes if they’ve been recommended by a doctor or midwife.
    • Maternity leave — 26 weeks of ordinary maternity leave and 26 weeks of additional maternity leave, making 1 year in total (if they work for an employer). Maternity leave may be taken no matter how long the woman has been with an employer, how many hours she works, or how much she is paid. She may be entitled to take some of this leave as Shared Parental Leave. A woman is not legally permitted to return to employment in the 2 weeks following childbirth (or 4 weeks if they work in a factory).
    • Maternity pay or maternity allowance.
    • Protection against unfair treatment, discrimination, or dismissal.
• Up-to-date detailed information on maternity rights and benefits is available from www.gov.uk:
  • Pregnant employees' rights.
  • Maternity pay and leave.

Basis for recommendation

Dietary advice

• Recommendations on dietary advice are based on clinical guidance from NICE Maternal and child nutrition: nutrition and weight management in pregnancy, and nutrition in children up to 5 years [NICE, 2025], expert opinion in a review article [Caro, 2020], and patient information from the Public Health Agency The pregnancy book [PHA, 2021], the NHS Healthy start, NHS Inform Ready steady baby, and the Royal College of Obstetricians and Gynaecologists (RCOG) Healthy eating and vitamin supplements in pregnancy.

Nutritional supplements

• Recommendations on folic acid and vitamin D are based on clinical guidance from NICE Maternal and child nutrition: nutrition and weight management in pregnancy, and nutrition in children up to 5 years [NICE, 2025] and Vitamin D: increasing supplement use in at-risk groups [NICE, 2014], expert opinion in review article [BMJ Best Practice, 2019], the BNF [BNF, 2021], and patient information from the Public Health Agency Publication The Pregnancy Book [PHA, 2021] and the Royal College of Obstetrics and Gynaecology Healthy Eating and Vitamin Supplements in Pregnancy.  

Exercise

• Recommendations on exercise during pregnancy are based on a NICE clinical guideline Weight management before, during and after pregnancy [NICE, 2010a], the UK Chief Medical Officers' Physical Activity Guidelines [UK CMO, 2019], and expert opinion in review articles  [BMJ Best Practice, 2019; Caro, 2020].
• The UK Chief Medical Officers report identified benefits of physical activity during pregnancy including reduction in hypertensive disorders, improved cardiorespiratory fitness, lower gestational weight gain, and reduction in risk of gestational diabetes [UK CMO, 2019].

Medicines and complementary therapies in pregnancy

• Information on use of paracetamol in pregnancy is based on a patient information leaflet Paracetamol from the UK Teratology information service. 
• Advice on herbal medications is from the NHS Specialist Pharmacist Service [SPS, 2019].

Alcohol, smoking, and recreational drugs during pregnancy

• Recommendations on what advice to give regarding alcohol, smoking, and recreational drugs during pregnancy are based on the NICE clinical guidelines Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors [NICE, 2018], Smoking: stopping in pregnancy and after childbirth [NICE, 2010b], and Antenatal care [NICE, 2021a], and patient information from the Public Health Agency The pregnancy book [PHA, 2021].

Avoiding toxoplasmosis

• Information on toxoplasmosis is based on guidance from Public Health England Toxoplasmosis: diagnosis, epidemiology and prevention [PHE, 2010] and Pregnancy: advice on contact with animals that are giving birth [PHE, 2017], and patient information from the RCOG Healthy eating and vitamin supplementation in pregnancy and The pregnancy book [PHA, 2021].

Travel during pregnancy

• Information on advice about travel during pregnancy is based on expert opinion in a review article [BMJ Best Practice, 2019], and patient information from the Royal College of Obstetricians and Gynaecologists Air travel and pregnancy, Public Health England Malaria: information for people travelling overseas and Zika virus: travel advice, and the Public Health Agency The pregnancy book [PHA, 2021].

What advice can I give regarding the risks and limitations of a fetal anomaly scan?

• Advise the parents that:
  • There are no known risks of an ultrasound scan; it is thought to be safe for the mother and baby.
  • At the fetal anomaly scan, the sonographer looks specifically for 11 conditions in the baby that are associated with mortality (for example anencephaly), morbidity (for example serious heart defects), or require immediate postnatal support (for example spina bifida).
  • A fetal anomaly scan is not perfect, does not have a 100% detection rate, and inevitably some conditions will be missed or misidentified. This means that there is a chance that a baby may be born with a condition that could not be seen on scan.
  • If a screening scan identifies a potential fetal abnormality, they will be offered referral to a fetal medicine specialist for a second opinion to confirm the diagnosis.
  • Screening is their choice and they do not have to have the scan. Some people want to find out if their baby has one of the 11 physical conditions and some do not. If they choose to have the scan, they may need to make important personal decisions based on the results. Whatever they decide, they will be supported by their healthcare team.
• Detailed patient information on antenatal screening, including risks and benefits, is available from Public Health England:
  • Screening tests for you and your baby.
  • 20-week screening scan. 
  • 11 physical conditions. 

Basis for recommendation

The information on the ultrasound scans offered during an uncomplicated pregnancy is based on expert opinion from the National Institute of Health and Care Excellence (NICE) guideline Antenatal care [NICE, 2021a] and guidance and patient information from Public Health England NHS Fetal Anomaly Screening Programme (FASP): programme overview [PHE, 2013b] and Screening in pregnancy: 20-week screening scan [PHE, 2021c].

Basis for recommendation

The recommendations on treating constipation in pregnancy are based on expert opinion in clinical guidance from the National Institute of Health and Care Excellence (NICE) Antenatal care [NICE, 2021a] and Schedule of antenatal appointments [NICE, 2021c], the World Health Organization (WHO) Recommendations on antenatal care for a positive pregnancy experience [WHO, 2017], and a Public Health Agency publication The pregnancy book [PHA, 2021].

Basis for recommendation

The recommendations on treating varicose veins in pregnancy are based on expert opinion in clinical guidance from the National Institute of Health and Care Excellence (NICE) Varicose veins: diagnosis and management (CG168) [NICE, 2013], the World Health Organization (WHO) Recommendations on antenatal care for a positive pregnancy experience [WHO, 2017], and a Public Health Agency publication The pregnancy book [PHA, 2021].

Basis for recommendation

The recommendations on managing and treating vaginal discharge in pregnancy are based on expert opinion in the National Institute of Health and Care Excellence (NICE) clinical guideline Antenatal care [NICE, 2021a].

Basis for recommendation

The recommendation on management of pelvic girdle pain is based on expert opinion in the National Institute of Health and Care Excellence (NICE) guideline Antenatal care [NICE, 2021a].

Basis for recommendation

The recommendations on treating haemorrhoids in pregnancy are based on expert opinion from the UK Teratology Information Service [UKTIS, 2020], the British National Formulary [BNF, 2021], and the Public Health Agency publication The Pregnancy Book [PHA, 2021].

Basis for recommendation

The recommendations on breech presentation are based on expert opinion in clinical guidance from the National Institute of Health and Care Excellence (NICE) Antenatal care [NICE, 2021a] and Schedule of antenatal appointments [NICE, 2021c].