5 George Attilakos1 and Timothy G. Overton2 1 Fetal Medicine Unit, University College London Hospital NHS Foundation Trust, London, UK 2 St Michael’s Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK The care of pregnant women presents a unique challenge to modern medicine. Most women will progress through pregnancy in an uncomplicated fashion and deliver a healthy infant requiring little medical or midwifery intervention. Unfortunately, a significant number will have medical problems that will complicate their pregnancy or develop such serious conditions that the lives of both themselves and their unborn child will be threatened. In 1928, a pregnant woman faced a 1 in 290 chance of dying from an obstetric complication related to the pregnancy; the most recent surveillance of maternal deaths between 2011 and 2013 put this figure at 1 in 34,394 [1]. Undoubtedly, good antenatal care has made a significant contribution to this reduction. The current challenge of antenatal care is to identify those women who will require specialist support and help while allowing uncomplicated pregnancies to progress with minimal interference. The antenatal period also allows the opportunity for women, especially those in their first pregnancy, to receive information from a variety of healthcare professionals regarding pregnancy, childbirth and parenthood. Women and their partners have the right to be involved in all decisions regarding their antenatal care. They need to be able to make informed decisions concerning where they will be seen, who will undertake their care, which screening tests to have and where they plan to give birth. Women must have access to evidence‐based information in a format they can understand. Current evidence suggests that insufficient written information is available especially at the beginning of pregnancy and information provided can be misleading or inaccurate. The Pregnancy Book [2] provides information on the developing fetus, antenatal care and classes, rights and benefits as well as a list of useful organizations. Many leaflets have been produced by the Midwives Information and Resource Service (MIDIRS) that helps women to make informed objective decisions during pregnancy. The Royal College of Obstetricians and Gynaecologists (RCOG) has also produced many pregnancy‐related patient information leaflets, most of them accompanying the relevant ‘Green‐top guidelines’ for clinicians. Written information is particularly important to help women understand the purpose of screening tests and the options that are available and to advise on lifestyle considerations including dietary recommendations. Available information needs to be provided at first contact and must take into account cultural and language barriers. Local services should endeavour to provide information that is understandable to those whose first language is not English and to those with physical, cognitive and sensory disabilities. Translators will be frequently required in clinics with an ethnic mix. There will be greater emphasis in the future in providing electronic sources of information. Women will want to be able to access their medical records digitally on smartphones and relevant information on pregnancy and childbirth through apps. While this would allow women to access up‐to‐date information enabling informed choices, it will require careful governance to ensure personal data safety, the accuracy of the information and availability for all. Couples should also be offered the opportunity to attend antenatal classes. Ideally such classes should discuss physiological and psychological changes during pregnancy, fetal development, labour and childbirth and how to care for the newborn baby. Evidence shows a greater acquisition of knowledge in women who have attended such classes compared with those who have not. At an early stage in the pregnancy women require lifestyle advice, including information on diet and food, work during pregnancy and social aspects, for example smoking, alcohol, exercise and sexual activity. Women should be advised of the benefits of eating a balanced diet that contains plenty of fruit and vegetables, starchy foods such as pasta, bread, rice and potatoes, protein, fibre and dairy foods. They should be informed of foods that could put their fetus at risk. Listeriosis is caused by the bacterium Listeria monocytogenes which can present with a mild flu‐like illness but is associated with miscarriage, stillbirth and severe illness in the newborn. Contaminated food is the usual source including unpasteurized milk, ripened soft cheeses and pâté. Toxoplasmosis contracted through contact with infected cat litter or undercooked meat can lead to permanent neurological and visual problems in the newborn if the mother contracts the infection during pregnancy. To reduce the risk, pregnant women should be advised to thoroughly wash all fruits and vegetables before eating and to cook all meats thoroughly, including ready‐prepared chilled meats. Written information from the UK Food Standards Agency (Eating While you are Pregnant) can also be helpful. For example, the Food Standards Agency advises women to reduce the consumption of caffeine to 200 mg/day (equivalent to two mugs of instant coffee), because of its association with low birthweight and miscarriage. Women who have not had a baby with spina bifida should be advised to take folic acid 400 µg/day from pre‐conception until 12 weeks of gestation to reduce the chance of fetal neural tube defects (NTDs). However, research analysis of the population incidence of NTDs has failed to show the efficacy of this strategy. This may be due to inadequate pre‐conceptual intake of folate and/or poor compliance. Suggestions of adding folate to certain foods (e.g. flour) to ensure population compliance (already occurring in some countries including the USA and Canada) remain debatable. Current evidence does not support routine iron supplementation for all pregnant women and can be associated with some unpleasant side effects such as constipation. However, any woman who is iron deficient must be encouraged to take iron therapy prior to the onset of labour as any excess blood loss at delivery will increase maternal morbidity. The intake of vitamin A (liver and liver products) should be limited in pregnancy to approximately 700 mg/day because of fetal teratogenicity. Women should be informed at the booking visit about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and while breastfeeding. Women are advised to take 10 µg of vitamin D per day as found in the Healthy Start multivitamin supplement. This is particuarly important in those most at risk, including women with limited exposure to sunlight, a body mass index (BMI) above 30 kg/m2, those of South Asian, African, Caribbean or Middle Eastern family origin and those with poor dietary intake of vitamin D. Because alcohol passes freely across the placenta, women should be advised not to drink excessively during pregnancy. The current UK Chief Medical Officer’s advice for pregnant women is that if a woman is pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to the baby to a minimum. Binge drinking and continuous heavy drinking cause the fetal alcohol syndrome, characterized by low birthweight, a specific facies, and intellectual and behavioural difficulties later in life. Although the evidence of harm from low levels of alcohol consumption is lacking, it is highlighted that ‘the safer option is not to drink alcohol at all during pregnancy’. Approximately 27% of women are smokers at the time of birth of their baby. Smoking is significantly associated with a number of adverse outcomes in pregnancy, including increased risk of perinatal mortality, placental abruption, preterm delivery, preterm premature rupture of the membranes, placenta praevia and low birthweight. While there is evidence to suggest that smoking may decrease the incidence of pre‐eclampsia, this must be balanced against the far greater number of negative associations. The recent NHS England care bundle for reducing stillbirth recommends carbon monoxide testing of all pregnant women at the antenatal booking appointment followed by referral, as appropriate, to a Stop Smoking service/specialist, based on an opt‐out system [3]. Although there is mixed evidence for the effectiveness of smoking cessation programmes, women should be encouraged to use local NHS Stop Smoking services and the NHS pregnancy smoking helpline [4]. Pregnant women who are unable to stop smoking should be informed of the benefits of reducing the number of cigarettes they smoke. A 50% reduction can significantly reduce the fetal nicotine concentration and is associated with an increase in the birthweight. Women who use recreational drugs must be advised to stop or be directed to rehabilitation programmes. Evidence shows adverse effects on the fetus and its subsequent development. Continuing moderate exercise in pregnancy or regular sexual intercourse does not appear to be associated with any adverse outcomes. Certain physical activity should be avoided such as contact sports which may cause unexpected abdominal trauma. Scuba diving should also be avoided because of the risk of fetal decompression disease and an increased risk of birth defects. Physically demanding work, particularly those jobs with prolonged periods of standing, may be associated with poorer outcomes such as preterm birth, hypertension and pre‐eclampsia, and small‐for‐gestational‐age babies but the evidence is weak and employment per se has not been associated with increased risks in pregnancy. Women require information regarding their employment rights in pregnancy and healthcare professionals need to be aware of the current legislation. Help for the socially disadvantaged and single mothers must be organized and ideally a one‐to‐one midwife allocated to support these women. The midwife should be able to liaise with other social services to ensure the best environment for the mother and her newborn child. Similar individual help is needed for pregnant teenagers and midwife programmes need to provide appropriate support for these vulnerable mothers. It is common for pregnant women to experience unpleasant symptoms in pregnancy caused by the normal physiological changes. However, these symptoms can be quite debilitating and lead to anxiety. It is important that healthcare professionals are aware of such symptoms, can advise appropriate treatment and know when to initiate further investigations. Extreme tiredness is one of the first symptoms of pregnancy and affects almost all women. It lasts for approximately 12–14 weeks and then resolves in the majority. Nausea and vomiting in pregnancy is one of the commonest early symptoms. While it is thought that this may be caused by rising levels of human chorionic gonadotrophin (hCG), the evidence for this is conflicting. Hyperemesis gravidarum, where fluid and electrolyte imbalance and nutritional deficiency occur, is far less common, complicating approximately 3.5 per 1000 pregnancies. Nausea and vomiting in pregnancy varies in severity but usually presents within 8 weeks of the last menstrual period. Cessation of symptoms is reported by most by about 16–20 weeks. Various non‐medical treatments have been advocated but the ones which appear to be effective are ginger and P6 (wrist) acupressure. According to the NICE antenatal care guideline, antihistamines (prochlorperazine, promethazine and metoclopramide) appear to be the pharmacological agents of choice, as they reduce nausea and are safe in relation to teratogenicity (metoclopramide has insufficient safety data to be recommended as a first‐line agent but no association with malformations has been reported), although they are associated with drowsiness [4]. However, the recent Cochrane review concludes there is a lack of high‐quality evidence to support any particular intervention [5]. Constipation complicates approximately one‐third of pregnancies, usually decreasing in severity with advancing gestation. It is thought to be related in part to poor dietary fibre intake and reduction in gut motility caused by rising levels of progesterone. Diet modification with bran and wheat fibre supplementation helps, as well as increasing daily fluid intake. Heartburn is also a common symptom in pregnancy but, unlike constipation, occurs more frequently as the pregnancy progresses. It is estimated to complicate one‐fifth of pregnancies in the first trimester, rising to about 75% by the third trimester. It is due to the increasing pressure caused by the enlarging uterus combined with the hormonal changes, leading to gastro‐oesophageal reflux. It is important to distinguish this symptom from the epigastric pain associated with pre‐eclampsia which will usually be associated with hypertension and proteinuria. Symptoms can be improved by simple lifestyle modifications such as maintaining an upright posture especially after meals, lying propped up in bed, eating small frequent meals and avoiding fatty foods. Proprietary antacid formulations, histamine H2‐receptor antagonists and proton‐pump inhibitors are all effective, although it is recommended that the latter be used only when other treatments have failed because of their unproven safety in pregnancy. Haemorrhoids are experienced by 1 in 10 women in the last trimester of pregnancy. There is little evidence for either the beneficial effects of topical creams in pregnancy or indeed their safety. Diet modification may help and in extreme circumstances surgical treatment considered, although this is unusual since the haemorrhoids often resolve after delivery. Varicose veins occur frequently in pregnancy. They do not cause harm and while compression stockings may help symptoms they unfortunately do not prevent varicose veins from appearing. The nature of physiological vaginal discharge changes in pregnancy. However, if it becomes itchy, malodorous or is associated with pain on micturition, it may be due to an underlying infection such as trichomoniasis, bacterial vaginosis or candidiasis. Appropriate investigations and treatment should be instigated. Backache is another potentially debilitating symptom, with an estimated prevalence of up to 61% in pregnancy. There is limited research on effective interventions for backache, but massage therapy, exercise in water and back care classes may be helpful in symptom relief. The UK Government defines domestic violence as: Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse, between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to: psychological, physical, sexual, financial or emotional (Home Office 2013). This includes issues of concern to black and minority ethnic communities, such as so‐called honour‐based violence, female genital mutilation and forced marriage. Family members are defined as mother, father, son, daughter, brother, sister and grandparents, whether directly related, in‐laws or stepfamily. Whatever form it takes, domestic abuse is rarely a one‐off incident and should instead be seen as a pattern of abusive and controlling behaviour through which the abuser seeks power over their victim. Typically the abuse involves a pattern of abusive and controlling behaviour which tends to get worse over time. The abuse can begin at any time – in the first year or after many years together. It may begin, continue or escalate after a couple have separated and may take place not only in the home but also in a public place. Domestic abuse occurs across society regardless of age, gender, race, sexuality, wealth and geography. However, the figures show that it consists mainly of violence by men against women. Children are also affected both directly and indirectly, and there is also a strong correlation between domestic violence and child abuse, with suggested overlap rates of between 40 and 60%. At least one in four women have experienced domestic violence and this figure is likely to be an underestimate because all types of domestic violence and abuse are under‐reported in health and social research, to the police and to other services. Pregnancy represents a particularly vulnerable time for women. A woman who is experiencing domestic abuse may have difficulties using antenatal care services because the perpetrator of the abuse may try to prevent her from attending appointments. The woman may be afraid that disclosure of the abuse will worsen her situation. Every hospital should have a domestic violence policy promoting the safeguarding welfare of adults at risk of harm, children and young people, and the unborn baby. All healthcare professionals should be alert to the symptoms or signs of domestic violence and have a clear understanding of local safeguarding policies to support vulnerable patients. Women should be given the opportunity to disclose domestic violence in an environment in which they feel secure. This can be encouraged by making available information and support tailored to women suspected to be experiencing domestic abuse and providing more flexible appointments if needed. Sources of support for women, including addresses and telephone numbers for social services, the police, support groups and women’s refuges, should be displayed in appropriate areas. A telephone number that is agreed with the woman and on which it is safe to contact her should be obtained from those at risk. When domestic violence is either suspected or known, an opportunity must be provided for discussions about individual circumstances in a quiet and private environment, and where the woman can be seen alone. The presence of a partner or a relative may constrain discussion of domestic violence and could place the woman in greater danger. The limitations of confidentiality must be clearly explained at the outset of the discussion. Women often find it difficult to disclose abuse even when they are asked about it and may deny that it is happening. Asking about abuse sends a clear message that abuse is wrong, and that the healthcare professional concerned takes the subject very seriously, giving a clear message that she can come back to the service when she feels ready to disclose. Practitioners may need to screen for domestic violence more than once and this should be a routine part of good clinical practice. In asking questions it is important that practitioners remain non‐judgemental, are empathetic, and listen and be aware of the woman’s reaction. If a woman discloses domestic abuse, immediate safety actions to reduce and manage the risk may be necessary. Actions will depend on whether the practitioner is present with the woman and she is safe in the immediate future, or whether she is still in a vulnerable location (e.g. with the perpetrator). Actions may include the following. A supportive action plan should be discussed and agreed with the woman. The healthcare professional will need to ensure that the risks to the individual and any children are not increased following disclosure and should discuss their immediate and longer‐term safety and the options available and appropriate for them. The plan of follow‐up and action should be documented to provide clarity around any actions to be taken. If an agreed action plan is not followed up, the individual may feel that she has not been listened to. If the individual is unable to follow through with actions discussed, this should be documented and further follow‐up and support offered. Such women need to be supported in their use of antenatal services by training healthcare professionals in the identification and care of at‐risk women. All hospital staff should be aware of their responsibilities in relation to safeguarding, including domestic violence. They will be able to achieve this through full compliance with the policy and procedures of their employing organization and attendance at appropriate mandatory training days. Recognition of the signs of domestic violence are now a required competency in Core Module 8: Antenatal Care in the RCOG Curriculum for Trainees. In addition, those undertaking the Advanced Training Skills Module in Forensic Gynaecology will be required to demonstrate significant skill in the recognition and management of domestic violence. Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as ‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non‐medical reasons’ [6]. The WHO classification of FGM is shown in Table 5.1. Table 5.1 WHO classification of female genital mutilation. FGM is a human rights violation and a form of child abuse because it breaches the United Nations Convention on the Rights of the Child. FGM is practised in 29 African countries but is also performed in non‐African countries. It is estimated that over 125 million women and girls have undergone FGM worldwide [7]. In England and Wales it is estimated that there are 137 000 women and girls living with FGM, as they were born in countries where FGM is practised. FGM is associated with many complications, both short term (e.g. bleeding and infection) and long term (e.g. genital scarring, urinary problems, dyspareunia, menstrual problems and obstetric complications). In 2015, the RCOG published the second edition of the Green‐top guideline on FGM and its management [8]. The obstetric complications include prolonged labour, perineal trauma, postpartum haemorrhage, increased risk of caesarean section, increased need for neonatal resuscitation and risk of early neonatal death and stillbirth. Given the potential severity of the obstetric complications, it is important that women with FGM are identified in the antenatal period. This is equally important for the protection of the unborn female child as she will be at risk of FGM as a child. All women should be asked about a history of FGM at their booking visit, irrespective of the country of origin. Ideally, they will be referred to a dedicated multidisciplinary service and the majority will require consultant‐led care. Some will require psychological support and some may require antenatal de‐infibulation, especially women with FGM type 3, if it is considered that vaginal assessment in labour is likely to be difficult. The RCOG Green‐top guideline also recommends screening for hepatitis C in addition to the routine antenatal infection screening tests. All women should have a documented plan of care for the antenatal, intrapartum and postnatal periods. FGM is illegal in the UK and many other countries. UK healthcare professionals have certain responsibilities when women with FGM are identified in the antenatal period or at other times. They must explain the UK law on FGM to the woman and be familiar with the requirements of the Health and Social Care Information Centre (HSCIC) FGM Enhanced Dataset. This requires the submission of non‐anonymized personal data and this must be explained to the woman. The recording of the data is different to reporting of the woman to the police or social services. The latter is not mandatory unless there is risk to the unborn child or existing children. The UK Department of Health has produced safeguarding risk assessment tools for this purpose (https://www.gov.uk/government/publications/safeguarding‐women‐and‐girls‐at‐risk‐of‐fgm). If FGM is confirmed in a girl under the age of 18, reporting to the police is mandatory [8]. Maternal iron requirements increase in pregnancy because of the demands of the developing fetus, the formation of the placenta and the increase in the maternal red cell mass. With an increase in maternal plasma volume of up to 50% there is a physiological drop in the haemoglobin (Hb) concentration during pregnancy. It is generally recommended that an Hb level below 110 g/L up to 12 weeks’ gestation or less than 105 g/L at 28 weeks signifies anaemia and warrants further investigation. A low Hb (85–105 g/L) may be associated with preterm labour and low birthweight. Routine screening should be performed at the booking visit and at 28 weeks’ gestation. While there are many causes of anaemia, including thalassaemia and sickle cell disease, iron deficiency remains the commonest. Serum ferritin is the best way of assessing maternal iron stores and if found to be low, iron supplementation should be considered. Routine iron supplementation in women with a normal Hb in pregnancy has not been shown to improve maternal or fetal outcome and is currently not recommended. Identifying the maternal blood group and screening for the presence of atypical antibodies is important in the prevention of haemolytic disease, particularly from rhesus alloimmunization. Routine antibody screening should take place at booking in all women and again at 28 weeks’ gestation irrespective of their rhesus D (RhD) status. Detection of clinically significant atypical antibodies should prompt referral to a specialist fetal medicine unit for further investigation and management. In the UK, 15% of women are RhD negative and should be offered anti‐D prophylaxis after potentially sensitizing events (e.g. amniocentesis or antepartum haemorrhage) and routinely at either 28 and 34 weeks’ gestation or once at 32 weeks depending on the dosage of anti‐D immunoglobulin used [4]. Consideration should also be given to offering partner testing, as anti‐D prophylaxis will not be necessary if the biological father is RhD negative. In the future, all RhD‐negative women may have routine diagnosis of fetal RhD status by analysing free fetal DNA in the maternal plasma. This will allow targeted anti‐D administration to women with RhD‐positive fetuses, which may result in cost savings and allow many women to avoid an unnecessary blood product. An observational service implementation pilot in three NHS units showed that at least 35% of RhD‐negative women can avoid unnecessary anti‐D administration and this service could be implemented with little additional cost and probably a saving, if the cost of the fetal DNA test is less than the cost of each anti‐D injection [9]. Screening for sickle cell disease and thalassaemias is important and each country will have a different screening strategy depending on the prevalence of these conditions. In the UK, this screening should be offered to all women as early as possible in pregnancy. If the regional sickle cell disease prevalence is high, laboratory screening should be offered. If the regional sickle cell disease prevalence is low, the initial screening should be based on the Family Origin Questionnaire; if this indicates high risk, then laboratory screening should be offered. Maternal blood should be taken early in pregnancy and with consent screened for hepatitis B, HIV and syphilis. Identification of women who are hepatitis B carriers can lead to a 95% reduction in mother‐to‐infant transmission following appropriate postnatal administration of vaccine and immunoglobulin to the baby. Women who are HIV positive can be offered treatment with antiretroviral drugs which, when combined with delivery by caesarean section (unless undetectable viral load) and avoidance of breastfeeding, can reduce maternal transmission rates from approximately 25% to 1% [10]. Such women need to be managed by appropriate specialist teams. Routine screening for rubella ended in England in April 2016, primarily because rubella infection levels in the UK are so low that they are defined as eliminated by the WHO criteria. Although the incidence of infectious syphilis is low, there have been a number of recent outbreaks in England and Wales. Untreated syphilis is associated with congenital syphilis, neonatal death, stillbirth and preterm delivery. Following positive screening for syphilis, testing of a second specimen is required for confirmation. Interpretation of results can be difficult and referral to specialist genitourinary medicine clinics is recommended. Current evidence does not support routine screening for cytomegalovirus, hepatitis C, toxoplasmosis or group B Streptococcus. Asymptomatic bacteriuria occurs in approximately 2–5% of pregnant women and when untreated is associated with pyelonephritis and preterm labour. Appropriate treatment will reduce the risk of preterm birth. Screening should be offered early in pregnancy by midstream urine culture. Chronic hypertension pre‐dates pregnancy or appears in the first 20 weeks, whereas pregnancy‐induced hypertension develops in the pregnancy, resolves after delivery and is not associated with proteinuria. Pre‐eclampsia is defined as hypertension that is associated with proteinuria occurring after 20 weeks and resolving after birth. Pre‐eclampsia occurs in 2–10% of pregnancies and is associated with both maternal and neonatal morbidity and mortality [11]. Risk factors include nulliparity, age 40 years and above, family history of pre‐eclampsia, history of pre‐eclampsia in a prior pregnancy, BMI greater than 35, multiple pregnancy and pre‐existing diabetes or hypertension. Hypertension is often an early sign that pre‐dates the development of serious maternal and fetal disease and should be assessed regularly in pregnancy. There is little evidence as to how frequently blood pressure should be checked and so it is important to identify risk factors for pre‐eclampsia early in pregnancy. In the absence of these, blood pressure measurement and urine analysis for protein should be performed at each routine antenatal visit and mothers should be warned of the advanced symptoms of pre‐eclampsia (frontal headache, epigastric pain, vomiting and visual disturbances). However, when risk factors are present, more frequent blood pressure measurements and urine analyses should be considered in addition to low‐dose aspirin prophylaxis (see Chapter 7). Currently there is little agreement as to the definition of gestational diabetes, whether and how we should screen for it and how to diagnose and manage it. However, there has been increasing evidence that ‘treating’ gestational diabetes is more beneficial than expectant management [12]. Consequently, the National Institute for Health and Care Excellence (NICE) recommends screening for gestational diabetes using risk factors (such as BMI >30 kg/m2 or previous gestational diabetes) in a healthy population [4]. Women with risk factors should be tested for gestational diabetes using the 2‐hour 75‐g oral glucose tolerance test. The importance of psychiatric conditions related to pregnancy was highlighted in the 2000–2002 Confidential Enquiry into Maternal and Child Health [13]. A significant number of maternal deaths due to or associated with psychiatric causes were also reported in the most recent enquiry [1]. At booking, women should be asked about history of significant mental illness, previous psychiatric treatment or a family history of perinatal mental health illness. If mental illness is suspected, further referral for assessment should be made. Good communication, particularly with primary care, is paramount. All women should be offered a ‘dating’ scan. This is best performed between 10 and 13 weeks’ gestation and the crown–rump length measured when the fetus is in a neutral position (i.e. not curled up or hyperextended). Current evidence shows that the estimated day of delivery predicted by ultrasound at this gestation will reduce the need for induction of labour at 41 weeks when compared with the due date predicted by the last menstrual period. In addition, a dating scan will improve the reliability of Down’s syndrome screening, diagnose multiple pregnancy and allow accurate determination of chorionicity and diagnose up to 80% of major fetal abnormalities. Women who present after 14 weeks’ gestation should be offered a dating scan where the estimated date of delivery is calculated by the ultrasound measurement of the head circumference. Current recommendations from NICE advocate that all women in the UK are offered the combined screening test for Down’s syndrome between 11 weeks and 13 weeks 6 days of gestation. Those that book later should be offered serum screening between 15 and 20 weeks’ gestation. The National Screening Committee further refined these guidelines in 2010, stating that the detection rate should be 90% for a screen‐positive rate of 2%. Because screening for Down’s syndrome is a complex issue, healthcare professionals must have a clear understanding of the options available to their patients. Unbiased, evidence‐based information must be given to the woman at the beginning of the pregnancy so that she has time to consider whether to opt for screening and the opportunity to clarify any areas of confusion before the deadline for the test passes. Recognizing the importance of this, NICE currently recommends that the first two antenatal appointments take place before 12 weeks’ gestation to allow the woman adequate time to make an informed decision about whether to have screening. Following a ‘screen‐positive’ result the woman needs careful counselling to explain that the test result does not mean the fetus has Down’s syndrome and to explain the options for further testing. A positive screen test does not mean further testing is mandatory. Likewise, a woman with a ‘screen‐negative’ result must understand that the fetus may still have Down’s syndrome. The recent introduction of fetal DNA non‐invasive prenatal testing (NIPT) allows another option prior to or instead of invasive testing because of the high sensitivity and low screen‐positive rate. Universal screening with NIPT may increase the detection rate to above 99% for the screened population but it has cost implications for publicly funded healthcare systems and has a significant failure rate. Contingent screening (offering NIPT to women with high‐risk combined screening) would have lower cost at the expense of lower detection rate. The detection rate would depend on the chosen cut‐off value of risk (e.g 1 in 150) for offering NIPT. With either strategy, the number of invasive procedures would be lower and hence there would be fewer miscarriages of healthy fetuses as a result of screening. The UK National Screening Committee commissioned a systematic review and cost‐consequence assessment of fetal DNA testing (https://legacyscreening.phe.org.uk/policydb_download.php?doc=552) and recommended offering NIPT to pregnant women whose chance of having a baby with Down’s, Edwards’ or Patau’s syndrome is greater than 1 in 150 [14]. The identification of fetal structural abnormalities allows the opportunity for in utero therapy, planning for delivery, for example when the fetus has major congenital heart disease, parental preparation and the option of termination of pregnancy should a severe problem be diagnosed. Major structural anomalies are present in about 3% of fetuses screened at 20 weeks’ gestation. Detection rates vary depending on the system examined, skill of the operator, time allowed for the scan and quality of the ultrasound equipment. Follow‐up data are important for auditing the quality of the service. Women must appreciate the limitations of such scans. Local detection rates of various anomalies such as spina bifida, heart disease or facial clefting should be made available. Written information should be given to women early in pregnancy explaining the nature and purpose of such scans, highlighting conditions that are not detected such as cerebral palsy and many genetic conditions. It is important to appreciate that the fetal anomaly scan is a screening test which women should opt for rather than have as a routine part of antenatal care without appropriate counselling. In 2010 the NHS Fetal Anomaly Screening Programme published a document for national standards and guidance for the mid‐trimester fetal anomaly scan; this was updated in 2015 [15]. These standards set out the basis for the ultrasound screening service in England, describing what can and, importantly, what cannot be achieved. Each antenatal clinic attendance allows the opportunity to screen for fetal well‐being. Auscultation for the fetal heart will confirm that the fetus is alive and can usually be detected from about 14 weeks of gestation. While hearing the fetal heart may be reassuring, there is no evidence of a clinical or predictive value. Likewise there is no evidence to support the use of routine cardiotocography in uncomplicated pregnancies. Physical examination of the abdomen by inspection and palpation will identify approximately 30% of small‐for‐gestational age fetuses [16]. Measurement of the symphysis–fundal height in centimetres starting at the uterine fundus and ending on the fixed point of the symphysis pubis has a sensitivity and specificity of approximately 27 and 88%, respectively, although serial measurements may improve accuracy. A risk stratification algorithm is recommended by the recent NHS England care bundle for reducing stillbirth [3] as well as the RCOG Green‐top guideline [16]. Women with one or more risk factors should have serial ultrasound scans to assess fetal growth, whereas low‐risk women should have growth assessment by antenatal symphysis–fundal height charts (customized or other established growth chart). Customized growth charts make adjustments for maternal height, weight, ethnicity and parity. However, there is no good‐quality evidence that their use improves perinatal outcomes [4]. Traditionally, women have been advised to note the frequency of fetal movements in the third trimester and report reduced fetal movements. Raising awareness of reduced fetal movement has been another element of the NHS England care bundle for reducing stillbirth [3]. Women should be given information and advice leaflet by week 24 of pregnancy and reduced fetal movements should be discussed at every subsequent visit. A protocol based on the relevant RCOG guideline should be in place for these women; this will lead to ultrasound scan for fetal growth, amniotic fluid and umbilical artery Doppler assessment if there are additional risk factors for fetal growth restriction or stillbirth. Antenatal care has been traditionally provided by a combination of general practitioners, community midwives, hospital midwives and obstetricians. The balance has depended on the perceived normality of the pregnancy at booking. However, pregnancy and childbirth is to a certain extent an unpredictable process. The frequency of antenatal visits and appropriate carer must be planned carefully, allowing the opportunity for early detection of problems without becoming over‐intrusive. A meta‐analysis comparing pregnancy outcome in two groups of low‐risk women, one with community‐led antenatal care (midwife and general practitioner) and the other with hospital‐led care, did not show any differences in terms of preterm birth, caesarean section, anaemia, antepartum haemorrhage, urinary tract infections and perinatal mortality. The first group had a lower rate of pregnancy‐induced hypertension and pre‐eclampsia, which could reflect a lower incidence or lower detection [17]. However, clear referral pathways need to be developed that allow appropriate referral to specialists when either fetal or maternal problems are detected. There is little evidence regarding women’s views on who should provide antenatal care. Unfortunately, care is usually provided by a number of different professionals often in different settings. Studies evaluating the impact of continuity of care do not generally separate the antenatal period from labour. The studies consistently show that with fewer caregivers women are better informed and prepared for labour, attend more antenatal classes, have fewer antenatal admissions to hospital and have higher satisfaction rates. Differences in clinical end‐points such as caesarean section rates, postpartum haemorrhage, admission to the neonatal unit and perinatal mortality are generally insignificant [4]. While it would appear advantageous for women to be seen by the same midwife throughout pregnancy and childbirth, there are practical and economic considerations that need to be taken into account. Nevertheless, where possible, care should be provided by a small group of professionals. The antenatal record needs to document clearly the care the woman has received from all those involved. It will also serve as a legal document, a source of useful information for the woman and a mechanism of communication between different healthcare professionals. There is now good evidence that women should be allowed to carry their own notes. Women feel more in control of their pregnancy and do not lose the notes any more often than the hospital! In addition, useful information will be available to clinicians should the woman require emergency care while away from home. Many areas of the UK are endeavouring to work towards a standard format for the records. This would be of benefit to those women who move between hospitals so that caregivers would automatically be familiar with the style of the notes. If we are to move to an electronic patient record, there must be general agreement in a minimum dataset and a standard antenatal record would be a step in this direction. There has been little change in how frequently women are seen in pregnancy for the last 50 years. In 2003, NICE produced a clinical guideline entitled Antenatal Care: Routine Care for the Healthy Pregnant Woman, which was revised in 2008 [4] and updated in 2013. This document recognized the large amount of information that needs to be discussed at the beginning of pregnancy, particularly with regard to screening tests. The first appointment needs to be early in pregnancy, certainly before 12 weeks if possible. This initial appointment should be regarded as an opportunity for imparting general information about the pregnancy such as diet, smoking and folic acid supplementation. A crucial aim is to identify those women who will require additional care during the pregnancy. A list of conditions for which additional care will be needed is provided at the NICE website (https://www.nice.org.uk/guidance/cg62/chapter/Appendix‐C‐Women‐requiring‐additional‐care). A urine test should be sent for bacteriological screen and a dating ultrasound scan arranged. Sufficient time should be set aside for an impartial discussion of the screening tests available, including those for anaemia, red‐cell antibodies, syphilis, HIV and hepatitis. Because of the complexity of Down’s syndrome screening, this too should be discussed in detail and supplemented with written information. Ideally another follow‐up appointment should be arranged before the screening tests need to be performed to allow further questions and to arrange a time for the tests following maternal consent. The next appointment needs to be around 16 weeks’ gestation to discuss the results of the screening tests. In addition, information about antenatal classes should be given and a plan of action made for the timing and frequency of future antenatal visits, including who should see the woman. As with each antenatal visit, the blood pressure should be measured and the urine tested for protein. The 20‐week anomaly scan should also be discussed and arranged and women should understand its limitations. At each visit the symphysis–fundal height is plotted, the blood pressure measured and the urine tested for protein. At 28 weeks’ gestation, blood should be taken for haemoglobin estimation and atypical red‐cell antibodies. Anti‐D prophylaxis should be offered to women who are rhesus negative. A follow‐up appointment at 34 weeks will allow the opportunity to discuss these results. At 36 weeks, the position of the baby needs to be checked and if there is uncertainty an ultrasound scan arranged to exclude breech presentation. If a breech is confirmed, external cephalic version should be considered. For women who have not given birth by 41 weeks, both a membrane sweep and induction of labour should be discussed and offered. Additional appointments at 25, 31 and 40 weeks are proposed for nulliparous women. In summary, a total of 10 appointments is recommended for nulliparous women and seven appointments for multiparous women, assuming they have uncomplicated pregnancies.
Antenatal Care
Aims of antenatal care
Antenatal education
Provision of information
Lifestyle concerns
Common symptoms in pregnancy
Domestic violence
Female genital mutilation
Type 1
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
Type 2
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)
Type 3
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)
Type 4
All other harmful procedures to the female genitalia for non‐medical purposes, for example pricking, piercing, incising, scraping and cauterization
Screening for maternal complications
Anaemia
Blood group and red cell alloantibodies
Haemoglobinopathies
Infection
Hypertensive disease
Gestational diabetes
Psychiatric illness
Screening for fetal complications
Confirmation of fetal viability
Screening for Down’s syndrome
Screening for structural abnormalities
Screening for fetal growth restriction
Organization of antenatal care
Who should provide the antenatal care?
Documentation of antenatal care
Frequency and timing of antenatal visits
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