Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice.

Starting antenatal care

Recommendations 1.1.1 to 1.1.3

Why the committee made the recommendations

No relevant evidence was identified and so the committee made the recommendations based on their knowledge and experience, and also made a research recommendation about how to start antenatal care. The committee discussed the ways in which women should be able to access antenatal care, but agreed that the configuration details would depend on local arrangements.

The committee agreed that antenatal service planning should take into account women's needs and circumstances, and should not discriminate against, for example, a limited ability to use and access online services, limited skills in English language or in literacy, or not being registered with a GP surgery. The committee were aware that for some women in vulnerable situations or with limited English language skills, there may be a delay in accessing and starting antenatal care.

The booking appointment should occur by 10 weeks of pregnancy but the initial contact and referral might have happened several weeks earlier, so the committee agreed that the referral contact should include provision of early pregnancy information, for example, public health messages for the woman about folic acid supplementation or stopping smoking. It is also important to identify women with specific needs or risk factors early on so that appropriate care can be provided from the beginning.

The committee agreed that it is important to have the contact details for the woman's GP to ensure that information can be shared between primary care and maternity services so that care is provided according to the woman's individual needs, and to identify potential safeguarding issues.

How the recommendations might affect practice

There is variation in current practice in how women access antenatal care and the time between women's first contact with a healthcare professional and subsequent steps. Enabling women to start their antenatal care through various routes, including through school nurses, community centres or refugee hostels, may have some implications on resources; however, these should be outweighed by the benefits of timely antenatal care. The recommendations should improve timely access to antenatal care for women in various situations, and improve early recognition of specific needs and risk factors so that care can be planned.

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Antenatal appointments

Recommendations 1.1.4 to 1.1.13

Why the committee made the recommendations

There was no new evidence to support changing from the existing recommended practice of women having their first antenatal (booking) appointment by 10+0 weeks.

Some women only contact, or are referred to, maternity services after 9+0 weeks. This 'late booking' may be particularly common among some socially vulnerable women or women with limited English language skills. Based on their knowledge and experience, the committee agreed that women who contact, or are referred to, maternity services after 9+0 weeks should have a booking appointment ideally within 2 weeks so that early pregnancy care, including information provision and screenings, can happen within the right timeframe. The committee agreed that it would be helpful to identify any underlying factors that may have led to the 'late booking' so that the woman's need for potential additional support or care can be considered and that any potential inequality and accessibility issues can be addressed.

There was no new evidence that led the committee to change from the existing recommended practice of arranging 10 appointments for nulliparous women and 7 appointments for parous women. Instead, the committee made a research recommendation about the ideal number and timing of antenatal appointments, including consideration for groups at higher risk of adverse outcomes.

The evidence on women's experience and satisfaction in relation to the number of antenatal appointments was mixed, but the committee agreed the importance of being flexible to meet women's needs.

There was evidence that women who needed to use interpreters found the service to be unreliable and inconsistent, so the committee made a specific recommendation highlighting that interpreters should always be available when needed (including, for example, at scan appointments) and that they should be independent of the woman and not, for example, a family member or a friend.

There was good evidence that women value having the same midwife throughout their antenatal care, although the review did not look at the benefits and harms of continuity of carer in relation to clinical- and cost-effectiveness outcomes. The NHS England's report Better Births: improving outcomes of maternity services in England – a five year forward view for maternity care recommends continuity of carer by 1 midwife who is part of a small team of midwives based in the community, so that they can get to know the woman and provide support to her throughout pregnancy all the way to the postnatal period.

Various health professionals or providers may be involved throughout the pregnancy, and the committee emphasised the need for good communication between different health professionals and providers.

How the recommendations might affect practice

The timing of the booking appointment and the number of appointments reflects current clinical practice. The recommendation about women who do not have a booking appointment arranged by 9+0 weeks may lead to more women attending booking appointments before 11 weeks and it may also reduce how long it takes to secure a booking appointment. However, this may also be challenging for services to organise.

The recommendation about offering additional or longer antenatal appointments depending on need may lead to a small increase in the number of antenatal appointments, but this is likely to be negligible and potentially have benefits later on.

The recommendation on the use of interpreters is not new but is not well implemented in all units, so may involve a change in practice.

In current practice, providing continuity of carer can be difficult to achieve and there can be significant resource implications; however, the recommendation reflects NHS England's recommendations.

The committee agreed that the recommendations would not result in a major change in practice but should reduce variation in practice and improve care for women.

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Involving partners

Recommendations 1.1.14 to 1.1.16

Why the committee made the recommendations

The committee recognised that women's home and family circumstances vary, and it is up to the woman to decide who she may want to involve in her antenatal care. Involving partners is an important part of antenatal care, and the World Health Organization has emphasised the importance of engaging with partners during pregnancy, childbirth and postnatally. The committee discussed the impact that a partner's support, lack of support, or their wellbeing can have on the wellbeing of the pregnant woman. The committee recognised that the woman's partner is often also an expectant parent and being involved in the antenatal care, if the woman so wishes, can provide information and support for them as well.

The committee discussed that partners can face many types of barriers when engaging with antenatal services. There was good quality evidence on partners' views and experiences of antenatal care that showed that women appreciate being able to involve their partners in antenatal care, but that this can be difficult, for example, because of the partner's work patterns. Therefore, the committee agreed that the services should consider adapting when to offer antenatal classes (for example, in the evenings or at the weekends) to enable partners to be involved if the woman wishes.

Evidence showed that partners can feel like bystanders in appointments if, for example, there is no space for them to sit with their partner. The committee agreed ways that antenatal services could promote partner involvement. The committee agreed that partners are not always given information, including on how partners can support the woman during and after pregnancy, and the general pregnancy information that women receive.

Increased use of virtual platforms for appointments may also improve partners' involvement in antenatal care. For example, this could enable the partner to attend remotely if the woman has a face-to-face appointment, or for the couple to attend together if she has a video appointment. However, the committee recognised that evidence on video consultations and appointments was not reviewed for this guideline, and the benefits, harms and experiences related to them is important to consider when planning services. The committee also agreed that it is important to carefully assess any potential inequalities issues that could be associated with video appointments, for example, among people with sensory impairments or language barriers, minority groups, or in relation to access to devices or internet connection.

How the recommendations might affect practice

The committee agreed that the recommendations may increase and promote the involvement of partners, while respecting the woman's decisions. The recommendations are not expected to have a large resource impact or be difficult to implement although there may be some organisational changes needed to support making the timing of antenatal classes more flexible.

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Taking and recording the woman's history

Recommendations 1.2.1 to 1.2.11

Why the committee made the recommendations

The recommendations were not developed by the usual NICE guideline systematic review process. A new evidence review was not considered necessary because the issues are covered by other NICE guidelines, or there is no clinical uncertainty or significant resource impact. Where there might be a potential limited resource impact, this could be justifiably offset by improved outcomes, avoidance of serious adverse outcomes or addressing inequalities. The recommendations were based on committee consensus on what is best practice, as well as other existing NICE guidelines.

Asking the woman about her past and present conditions and experiences in relation to her physical, obstetric, psychological, emotional and social health enables potential risk factors to be identified and managed. The committee used their knowledge and experience to list the factors that should be discussed so that appropriate action can be taken, and care tailored to the woman's needs. For example, it is important to note which pharmacological and non-pharmacological remedies the woman uses so that current medication can be reviewed in light of pregnancy. It is important that women do not automatically stop using their regular medication without consultation. This discussion also allows for individualised advice on safe medicine use during pregnancy and can help with identifying any health issues that may have otherwise not come up.

The committee also agreed that it is important to discuss the woman's home and family situation and the available support she has. There may be issues that can impact on her wellbeing, for example, lack of support, illness in the family or a partner's substance use issues.

Sometimes there may be a reason to review the woman's previous medical records, for example, when her previous maternity care has been in a different organisation, she cannot recall details of a potentially significant issue, or the discussion somehow triggers a concern.

The committee agreed that healthcare professionals should be aware of the disproportionate maternal mortality and stillbirth rates among women and babies from black and Asian backgrounds and those living in deprived areas, as highlighted by the 2020 MBRRACE-UK reports on maternal mortality and perinatal mortality. This increased risk of death indicates that interventions to improve engagement, support and closer monitoring need to be explored. Future research could help understand the mechanisms underlying these disparities and what interventions could improve the outcomes. In general, action on the wider determinants of health, including different social, economic and environmental factors, is also needed to overcome such inequalities.

The committee agreed that domestic abuse puts both the woman and her baby at risk of harm, so it is important that all pregnant women are asked about it in a kind, sensitive way. Pregnancy can sometimes be a trigger for domestic abuse or existing domestic abuse can continue or worsen during pregnancy, so it is important that women feel that they can disclose it safely so that they can be supported, and interventions put in place if needed. Although partner involvement in antenatal care is welcome, it is also important to ensure that there is an opportunity to discuss domestic issues privately with the woman.

The committee recognised the need to identify women who have undergone female genital mutilation (FGM) or whose unborn baby girl might be at risk of FGM so that appropriate safeguarding can take place. In the context of this guideline, this could be the pregnant woman, or the unborn baby when there is a family history or tradition of FGM. There is a mandatory duty to report suspected or known FGM in under 18s. The Department of Health and Social Care has produced a quick guide for healthcare professionals on FGM safeguarding and risk assessment, which includes information about countries where FGM is practised, and practical advice on how to start the conversation.

Identifying underlying cardiac problems is important because cardiovascular disease is the leading cause of death among women in the UK during and after pregnancy, according to the 2019 report MBRRACE-UK: Saving lives, improving mothers' care – lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016–18. Some women are at a higher risk of undiagnosed structural cardiac problems, such as women with a family history of cardiac abnormalities or women who were brought up in a country with a high incidence of rheumatic fever. Clinical assessment cannot identify all cardiac problems that cause maternal mortality, but it might pick up structural heart disease or concerns that warrant further investigations. Early identification of underlying cardiac conditions allows these women to receive appropriate care during their pregnancy, childbirth and postnatal period, and potentially avoid poor outcomes.

The committee also agreed the importance of information sharing between the maternity unit and the GP, and agreeing this with the woman. This is particularly important if the woman has self-referred (because the GP may be unaware of her pregnancy), and if women have a complex medical, psychological or social history (because different agencies may need to be involved in her and her baby's care).

Antenatal appointments are opportunities for continued monitoring and risk assessment on the health and wellbeing of the woman and her baby. They also allow for regular reassessments of women's antenatal care needs and plans.

How the recommendations might affect practice

The recommendations largely reflect current best practice. Clinical assessment for cardiac conditions is not always done for women who may be at an increased risk so this recommendation may change practice to some extent. The number of women this recommendation applies to is relatively small and the potentially life-saving benefit of this simple examination outweighs the potential cost and resource implications.

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Examinations and investigations

Recommendations 1.2.12 to 1.2.17

Why the committee made the recommendations

Most of the issues are covered by national screening programmes or other NICE guidance, so no new evidence review was needed. The committee agreed, by consensus, any other recommendations where there is no clinical uncertainty or significant resource impact.

The timing of the ultrasound scans aligns with the NHS fetal anomaly screening programme.

It is important that women understand the potential implications of each of the tests being offered so that they have the opportunity to accept or decline.

How the recommendations might affect practice

The recommendations reflect current practice and no change in practice is expected.

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Venous thromboembolism

Recommendations 1.2.18 to 1.2.20

Why the committee made the recommendations

The committee based the recommendations on the evidence on independent risk factors for venous thromboembolism in pregnancy, their knowledge and experience, and the NICE guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. The evidence on independent risk factors for venous thromboembolism during pregnancy did not assess the accuracy of tools used to measure the risk, so the committee recommended that tools should meet certain quality criteria. They agreed that an example of a tool that might be used is the risk assessment tool in the Royal College of Obstetricians and Gynaecologists' green-top guideline on reducing the risk of venous thromboembolism during pregnancy (2015), which is commonly used in practice.

The committee highlighted some risk factors in the evidence review (blood type A or B, miscarriage after 10 weeks in the current pregnancy and history of previous blood transfusion) that are not always incorporated into commonly used venous thromboembolism tools. However, they agreed not to include them specifically in the recommendations because it could give a false impression that these factors were more important than others or lead to overtreatment.

The committee agreed that women assessed as being at an increased risk of venous thromboembolism should be offered referral to an obstetrician so that a risk management plan can be made, for example, starting thromboprophylaxis.

How the recommendation might affect practice

The recommendation reflects current practice and no change in practice is expected.

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Gestational diabetes

Recommendations 1.2.21 and 1.2.22

Why the committee made the recommendations

Guidance on risk assessment for and identification of gestational diabetes is covered by the NICE guideline on diabetes in pregnancy.

How the recommendations might affect practice

The recommendation reflects current practice and no change in practice is expected.

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Pre-eclampsia and hypertension in pregnancy

Recommendations 1.2.23 to 1.2.28

Why the committee made the recommendations

Guidance on risk assessment and risk reduction for pre-eclampsia is covered by the NICE guideline on hypertension in pregnancy. Although the guideline implies that pregnant women will be routinely tested for proteinuria, it does not explicitly recommend this. Therefore, the committee agreed that, in line with current practice, urine testing for proteinuria should be offered at every routine face-to-face appointment.

There was little evidence on the setting and technique for monitoring blood pressure during pregnancy, so the committee made the recommendations based on their knowledge and experience and existing NICE guidance. The committee were aware that the British and Irish Hypertension Society lists blood pressure measurement devices validated for use in pregnancy. This has also been noted in the NICE guideline on hypertension in adults.

The committee agreed that monitoring blood pressure and testing for proteinuria at every routine face-to-face antenatal appointment enables hypertension and pre‑eclampsia to be identified and treated early, which is important because they can have severe consequences.

Guidance on care for pregnant women with gestational or chronic hypertension is covered by the NICE guideline on hypertension in pregnancy.

How the recommendations might affect practice

The recommendation reflects current practice and no change in practice is expected.

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Monitoring fetal growth and wellbeing

Recommendations 1.2.29 to 1.2.35

Why the committee made the recommendations

Risk assessment starting in early pregnancy enables increased monitoring of babies who are at an increased risk of fetal growth restriction, which is associated with fetal morbidity and mortality. The committee were aware of available risk assessment tools, such as those in the Royal College of Obstetricians and Gynaecologists' guideline on the investigation and management of the small-for-gestational-age fetus or the NHS saving babies' lives care bundle version 2.

Evidence showed that ultrasound scans and symphysis fundal height measurement do not accurately predict a baby being born small or large for gestational age. However, the committee agreed that the current routine practice of using symphysis fundal height measurement to monitor fetal growth should be used, because it is a simple and low-cost intervention and can alert to further investigations when concerns arise about the baby being either larger or smaller than expected for gestational age. When the symphysis fundal height measurement is large for gestational age, ultrasound scans could be used to assess the size of the baby and the volume of amniotic fluid. Small-for-gestational-age babies are at an increased risk of perinatal mortality and morbidity; therefore, when this is suspected, further investigations should be done to monitor the growth and wellbeing of the baby, taking into consideration the full clinical picture.

The committee were aware that many women may request routine ultrasound scans in late pregnancy, but available evidence showed no benefit from routine ultrasound in late pregnancy (from 28 weeks) for uncomplicated singleton pregnancies. However, the absence of effect found in the evidence does not mean that there is definitely no effect. There was also no evidence on maternal anxiety in relation to routine ultrasound scanning. The committee were in favour of research on this in the future; however, a research recommendation was not prioritised because there is a good amount of evidence on other key outcomes.

The committee were aware that cases of stillbirth have been linked to reduced fetal movements. Therefore, structured fetal movement awareness packages have been trialled. Evidence on the use of a structured fetal movement awareness package, such as the one described in the UK trial Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM), did not detect a reduction in stillbirths or perinatal mortality but did find that there were more interventions at birth, including more caesarean births and inductions of labour, and fewer spontaneous vaginal births. Another study from Sweden compared giving a leaflet to pregnant women teaching them a method of being aware of fetal movements, with usual care. No clinically important benefits or harms were detected, including no difference in perinatal mortality, although there was a small, but statistically significant, reduction in births after 41+6 weeks and fewer caesarean births. Health economic evaluation did not establish cost effectiveness for either of these structured awareness packages.

Although the available evidence did not support the use of structured packages, the committee agreed that fetal movements should be discussed routinely and women's concerns should be taken seriously. The committee agreed that there is no agreed definition of normal fetal movements. Discussing the topic of babies' movements in the womb and how they change throughout the pregnancy can help women recognise changes to their own baby's movement patterns. When there are concerns, an assessment of the woman's wellbeing and the baby's wellbeing and size should be done.

How the recommendations might affect practice

The recommendations on fetal growth monitoring largely reflect current practice, although in some maternity units it is common to offer women with uncomplicated singleton pregnancies ultrasound scans after 28 weeks to monitor the baby, so there might be a change of practice for these units and some potential cost savings. On the other hand, there may be some more scans due to suspected large for gestational age.

Current practice for managing reduced fetal movements is to follow the NHS saving babies' lives care bundle version 2. The recommendations in this guideline similarly emphasise the importance of recognising and reporting concerns on fetal movements and acting on those concerns by assessing the woman and the baby.

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Breech presentation

Recommendations 1.2.36 to 1.2.38

Why the committee made the recommendations

There was not enough evidence to support routine ultrasound at 36+0 weeks to 39+0 weeks to identify breech presentation, so the committee did not change the current standard practice of offering abdominal palpation with selective ultrasound when breech is suspected.

Because of the lack of evidence, the committee made a research recommendation to compare routine ultrasound scans from 36+0 weeks with selective ultrasound scans.

In the case of breech presentation, the committee agreed that a discussion about the different options and their potential benefits, harms and implications is needed to ensure an informed decision. External cephalic version is standard practice for managing breech presentation in uncomplicated singleton pregnancies at or after 36+0 weeks. Head-down vaginal birth is preferred by many women and the evidence suggests that external cephalic version is an effective way to achieve this.

How the recommendations might affect practice

The recommendations reflect current clinical practice and no change in practice is expected.

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Communication – key principles

Recommendations 1.3.1 to 1.3.6

Why the committee made the recommendations

The committee agreed that the key principles of care in the antenatal period are to listen to women and be responsive to their needs, in line with the findings of the Ockenden report on maternity services at the Shrewsbury and Telford hospital NHS trust, and to enable women to make informed decisions about their care, in line with the Montgomery ruling. The committee emphasised that women should be supported in their decision making even when their preferences and values differ from those of the healthcare professionals.

The evidence did not show a particular benefit from any one specific approach to giving information, although 1 study found that supplementing information provided face-to-face with online information increased knowledge. The committee based the recommendations on their knowledge and experience.

The committee agreed that information should meet the needs of the woman, for example, taking into account any language barriers, learning disabilities or other needs. Most antenatal care information is given in a one-to-one or couple discussion. Offering other formats to supplement this can help improve understanding and engagement, including written materials and group discussions in antenatal classes or, in some cases, group antenatal appointments.

There was evidence that women value information that is relevant to their own circumstances. The committee agreed that healthcare professionals should explore the level and accuracy of the woman's (and her partner's) existing knowledge and understanding of the topic. The committee discussed the importance of allowing sufficient time for discussions.

How the recommendations might affect practice

The recommendations largely reflect current practice.

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Information about antenatal care

Recommendations 1.3.7 to 1.3.18

Why the committee made the recommendations

The committee agreed, based on the evidence and their knowledge and experience, that if women are given information about antenatal care, their schedule of appointments and what happens at different appointments and stages of pregnancy, they are more likely to be engaged, follow advice and share their concerns with healthcare professionals.

There was no evidence identified to inform the timing of information provision, but the committee agreed that it is important to have a staged approach and cover topics relevant to each stage of pregnancy.

The first antenatal (booking) appointment is an opportunity to discuss and share information about various practical issues related to pregnancy and antenatal care so that the woman knows what to expect and how to get support. The evidence showed that partners also value practical information throughout the pregnancy. For example, in relation to safe use of medicines in pregnancy, the committee were aware of the UK Teratology Information Service's information resources on best use of medicines in pregnancy (bumps).

The evidence suggested that women want information on how behavioural factors, such as smoking, alcohol, diet and physical activity may affect them and their baby's health. The evidence also highlighted how emotional these topics could be for women and that women may feel judged or patronised. The committee agreed that it is important to have these discussions in a sensitive manner that supports individual women. Guidance on all these issues is covered by other NICE guidelines or government documents.

The committee recognised that pregnant women and their partners often look for information and support from various sources, such as websites, and not all of them are necessarily evidence-based, so signposting to trusted resources may be helpful.

There was some evidence that women and their partners valued information and discussion around the transition to parenthood, and the changes that pregnancy and becoming a parent will bring to their life and relationship. The committee were aware of various available resources that could be helpful for parents, particularly new parents.

The evidence showed that women want information on their options for giving birth. The committee agreed that these discussions should start, at the latest, around the start of the third trimester, depending on the woman's preferences and circumstances. The committee agreed, in line with the Montgomery ruling, that discussing the implications, benefits and risks is fundamental to making shared and informed decisions. Guidance on making decisions about place of birth, mode of birth and prolonged pregnancy are also covered by other NICE guidelines. The committee were also aware that NICE is developing a guideline on the prevention and non-surgical management of pelvic floor dysfunction.

Considering the amount of new information given at the beginning of antenatal care, discussions around practical aspects related to labour, childbirth and postnatal care are often more appropriate later on in pregnancy. There was some evidence that healthcare professionals thought that providing information on emotional attachment and bonding could improve women's confidence and increase their preparedness for birth. Further recommendations about promoting emotional attachment and bonding, as well as planning and managing infant feeding, are covered by the NICE guideline on postnatal care.

How the recommendations might affect practice

The recommendations will improve consistency of care and reinforce best practice.

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Antenatal classes

Recommendations 1.3.19 to 1.3.21

Why the committee made the recommendations

Evidence among nulliparous women showed that women who went to antenatal classes were more likely to have their cervix dilated by 3 cm or more on admission to labour. A dilated cervix on admission may reduce the need for interventions. This may indicate that women who attended antenatal classes have better coping strategies and the confidence to deal with pain at home in the early stages of labour. There was no evidence about the most effective content for antenatal classes, so the committee made the recommendations based on their experience.

The committee recognised that there may be multiparous women who could also particularly benefit from antenatal classes, so providing them for these women should be considered.

The committee recognised that some groups of women may be less likely to attend antenatal classes (for example, some women from low income or disadvantaged backgrounds or minority ethnic groups, or those for whom English is not their first language). The committee agreed that in order to increase engagement with antenatal classes, service providers should ensure that classes are accessible, welcoming and adapted to meet the needs of local communities.

How the recommendations might affect practice

The recommendations reflect current practice. However, adapting classes to the needs of the local communities might involve some reorganising of practices.

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Peer support

Recommendations 1.3.22 and 1.3.23

Why the committee made the recommendations

The evidence showed that peer support could offer helpful and valuable care and guidance during the antenatal period. There was evidence among women from particular subpopulations, such as migrant women, women of lower socioeconomic status, women with intellectual disabilities, or younger women, and the committee agreed that peer support groups among women in similar circumstances might be particularly helpful.

The committee discussed that peer support, including group peer support, volunteer peer support, doula support and online support, is usually provided through 'third sector' services, and they agreed that healthcare professionals should give women information about how to contact local and national services. Although there was little evidence on partners' experiences of peer support, in the committee's experience, some partners find peer support services for partners helpful.

How the recommendations might affect practice

The recommendations reflect current best practice.

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Sleep position

Recommendations 1.3.24 and 1.3.25

Why the committee made the recommendations

The evidence suggested that there is an increased risk of stillbirth and babies being born small for gestational age after 28 weeks if women fall asleep on their backs. The committee agreed that there is some uncertainty about this risk because the evidence was from relatively small studies whose design made it difficult to assume that sleep position caused the adverse outcomes. The committee recognised that further research is unlikely because conducting sufficiently powered prospective cohort studies is not feasible given the relatively low incidence of stillbirth (1 in every 244 births in England and Wales according to 2018 Office for National Statistics [ONS] data). The committee also noted that not all the included studies used the same definition of stillbirth and that only 1 study reported data according to whether the stillbirth occurred at term or at preterm. On balance, the committee agreed that the evidence was strong enough to advise women to try to avoid going to sleep on their back after 28 weeks.

The committee knew from their experience that providing practical advice about risk reduction is extremely important for pregnant women. They discussed reassuring women about sleep positions, aids that could make it easier for pregnant women not to go to sleep on their backs and maintain this position when sleeping, for example, by using pillows.

The committee also agreed that the reason for this advice should be explained, and they recognised the potential anxiety and feelings of guilt that women may experience, for example, if they wake up on their backs.

How the recommendations might affect practice

Healthcare professionals may need to spend more time talking to women about sleep position in pregnancy, but the recommendations are not expected to have a significant cost or resource impact.

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Nausea and vomiting

Recommendations 1.4.1 to 1.4.7

Why the committee made the recommendations

Nausea and vomiting in pregnancy can affect daily functioning and quality of life, and can cause significant worry and upset. Based on their knowledge and experience, the committee agreed that it is important to reassure pregnant women who experience mild‑to‑moderate nausea and vomiting that these are common symptoms in early pregnancy and will usually settle later in the second trimester.

However, the committee recognised that many pregnant women expect nausea and vomiting in pregnancy and might even tolerate significant symptoms and try various self-help approaches before seeking medical advice. It is therefore important to take it seriously when women do seek help.

Some women prefer to use non-pharmacological treatments whereas others may prefer pharmacological treatments, so both options are recommended.

There was some evidence that ginger is effective in treating mild‑to‑moderate nausea and vomiting in pregnancy compared with placebo, and this may be an option particularly for women who want to try a non-pharmacological option.

There was evidence on a wide variety of pharmacological treatments, many of which are commonly used in current practice. The evidence on the medicines varied in quality and for some medicines, no evidence was found. Metoclopramide hydrochloride was supported by good quality evidence showing that it was effective in improving symptoms. Ondansetron was also found to be effective in improving symptoms. A combination drug with pyridoxine and doxylamine is currently the only drug licensed for this indication, but the evidence is very old and of low quality and did not show a convincing effect on symptom improvement. Evidence on histamine H1 receptor antagonists was of very low quality and not particularly convincing. Studies on pyridoxine hydrochloride showed differing results, with larger trials showing no improvement in symptoms. No evidence was identified on the effectiveness of cyclizine hydrochloride alone in pregnant women, so the committee made a research recommendation on the effectiveness of medication for women with nausea and vomiting in pregnancy.

The treatment options have different advantages and disadvantages, including effectiveness in relieving symptoms, safety and other considerations, which have been summarised in a table to help with decision making. The committee used information available from the British National Formulary (BNF), the UK Teratology Information Service monographs and patient information leaflets, and the manufacturers' summaries of product characteristics to inform women about the potential effects on the baby. The committee recognised that women are often concerned about the possible adverse effects of medicines on the baby and that these should be discussed in the context of understanding the small risk of adverse outcomes unrelated to medicine use.

The evidence for treating the more severe form of nausea and vomiting in pregnancy did not generally support any different treatment options from those used for mild and moderate nausea and vomiting in pregnancy. An exception was for acupressure combined with standard care where the evidence showed benefits in relieving symptoms in women with moderate‑to‑severe nausea and vomiting in pregnancy, which was not shown for women with mild and moderate nausea and vomiting. Therefore, the committee recommended that acupressure could be considered for women with moderate‑to‑severe nausea and vomiting as an additional treatment.

No recommendation was made on the use of corticosteroids as a treatment for severe nausea and vomiting in pregnant women because, despite research in this area, no evidence was found to support its use. The committee discussed that although corticosteroids have well-known harms, the benefits can outweigh them so that some units use corticosteroids in severe cases of nausea and vomiting in pregnancy, and so a research recommendation on the effectiveness of corticosteroids for women with severe nausea and vomiting in pregnancy was made.

Some women with moderate‑to‑severe nausea and vomiting in pregnancy might need intravenous fluids. The evidence showed no difference in most outcomes between offering intravenous fluids in an inpatient or outpatient setting. Offering them to an outpatient is less expensive, reduces time spent in hospital and, in the committee's experience, is generally preferred by women. Inpatient care may be needed when severe nausea and vomiting persists despite treatment. Hyperemesis gravidarum can have serious harmful consequences, and treatment and care in hospital may be needed. It should be noted that this guideline only covers treatments to manage nausea and vomiting in pregnancy and comprehensive management of hyperemesis gravidarum, which may include nutritional interventions, is not covered by this guideline on routine antenatal care.

How the recommendations might affect practice

The treatment options are all used in current practice but there may be a change in practice in encouraging shared decision making for different options. This may mean that those prescribing medicines may need to spend more time discussing the options with the woman.

An increase in giving intravenous fluids as an outpatient service instead of an inpatient service could bring cost savings.

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Heartburn

Recommendations 1.4.8 and 1.4.9

Why the committee made the recommendations

There was no evidence on whether giving lifestyle and diet information to pregnant women with heartburn is effective, but the committee agreed, based on their own knowledge and experience, that it may help. This is supported by guidance for the general adult population in the NICE guideline on gastro-oesophageal reflux disease and dyspepsia.

The committee recommended considering either antacid or alginate therapy for women with heartburn in pregnancy because there is evidence that they are equally effective. These medicines are available over the counter. Because the studies examined various antacid and alginate remedies, the committee agreed that they could not make a more specific recommendation.

The committee did not make any recommendations about acupuncture or proton pump inhibitors (PPIs) because, although there was some evidence that acupuncture is effective in alleviating heartburn and that PPI use in the first trimester is not harmful to the baby, it was of very low quality and not good enough to support recommending them to be used routinely. In addition, there was no evidence on H2 receptor antagonist (H2RA) therapy to treat heartburn in pregnancy.

How the recommendations might affect practice

The recommendations reflect current clinical practice.

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Symptomatic vaginal discharge

Recommendations 1.4.10 to 1.4.14

Why the committee made the recommendations

There was limited evidence on the effectiveness of treatments for symptomatic vaginal discharge in pregnant women, so the committee used their knowledge and clinical experience to make the recommendations. The committee agreed that some women can find an increase in vaginal discharge distressing or uncomfortable, so it is important to reassure women that it is a normal feature of pregnancy. However, women should also be made aware of the symptoms and signs of infection that may need further action, because there is a small chance that some infections could lead to complications.

Candidiasis (thrush) is often an easily identifiable cause of symptomatic vaginal discharge and may not need a formal investigation. However, if there is doubt about the cause, a vaginal swab could be used. It is important that possible sexually transmitted infections are appropriately investigated so that they can be treated, because they could have an impact on the baby.

The evidence on antifungal treatment to treat symptomatic vaginal discharge because of vaginal candidiasis was very limited, imidazole being the only drug class being studied. However, imidazole (for example, clotrimazole or econazole) was consistently shown to be effective.

The evidence on the benefits and harms of antibiotics to treat symptomatic vaginal discharge due to bacterial vaginosis was also very limited. There was only evidence on oral amoxicillin (which is not commonly prescribed in current practice for this indication) and oral metronidazole. The committee were aware of evidence among asymptomatic populations that antibiotics are effective in treating the underlying infection, but the committee agreed that it cannot be assumed that they would be effective in relieving symptomatic vaginal discharge. The committee noted that it is common practice to prescribe vaginal rather than oral antibiotics for this indication – in particular, clindamycin or metronidazole. Combining this with their knowledge and experience, they recommended that either oral or vaginal antibiotics could be considered. The NICE guideline on antimicrobial stewardship gives guidance on good practice in prescribing antimicrobials.

No evidence was identified on the effectiveness of metronidazole to treat symptomatic vaginal discharge because of vaginal trichomoniasis, therefore no recommendations were made.

How the recommendations might affect practice

The committee agreed that the recommendations will reinforce current best practice and standardise care.

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Pelvic girdle pain

Recommendation 1 4.15

Why the committee made the recommendation

There was evidence of varying quality from several randomised controlled trials that exercise advice from a physiotherapist may reduce pain intensity and pelvic-related functional disability. The committee recommended referral to physiotherapy services rather than to a physiotherapist because, in some cases, information and advice could be given over the telephone or in an email or letter rather than in a face-to-face appointment.

Moderate quality evidence from 1 randomised controlled trial showed that a non-rigid lumbopelvic belt together with general information about anatomy, body posture and ergonomic advice reduced pelvic girdle pain intensity, compared with exercise advice and information, and information only. However, it did not have an impact on functional status in daily activities. No evidence was identified about adverse effects of using a lumbopelvic belt. Providing a non-rigid lumbopelvic belt was also found to be cost effective based on an economic evaluation, but because the clinical evidence base was limited, the committee agreed not to make a strong recommendation.

The committee agreed that there was not enough evidence to show that manual therapy alone had any benefits for women with pelvic girdle pain, so did not make a recommendation. The committee agreed that the evidence for acupuncture to treat pelvic girdle pain was mixed, of poor quality and therefore not adequate enough to justify a recommendation that would have a substantial resource impact.

How the recommendation might affect practice

Current practice for pregnancy-related pelvic girdle pain is to offer analgesics (for example, paracetamol) and provide information about lifestyle and health changes. Some hospitals also have access to physiotherapy services. Providing a lumbopelvic belt is not current practice in all units, so the committee recognised that the recommendation may have cost implications. However, health economic modelling showed that it is cost effective even if women are referred for physiotherapy. The recommendation may increase the number of pregnant women seeking referral to physiotherapy services.

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Unexplained vaginal bleeding after 13 weeks

Recommendations 1.4.16 to 1.4.21

Why the committee made the recommendations

There was very little evidence, so the committee used their knowledge and experience to make recommendations. They took into account the risks associated with a delay in assessing and treating unexplained vaginal bleeding in pregnancy, the possibility that anti‑D injections may be needed for women who are rhesus D‑negative, the need to exclude a low-lying placenta (placenta praevia) and that corticosteroids may be needed if there is a risk of preterm birth.

The committee agreed that a review in secondary care is needed when unexplained vaginal bleeding occurs after 13 weeks of pregnancy. Evidence on the effectiveness of hospitalisation was limited, with only 1 retrospective study that showed no difference in the number of fetal deaths whether women were admitted to hospital or discharged on the day they presented. Because of limited evidence, the committee made a research recommendation on the effectiveness of hospitalisation compared with outpatient management for pregnant women with unexplained vaginal bleeding.

The committee agreed that hospitalisation should be considered for monitoring, administering corticosteroids and neonatal unit care if the baby is born preterm. Discussion with the woman about the possibility of preterm birth may also be helpful.

How the recommendations might affect practice

The recommendations reflect current practice.

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  • National Institute for Health and Care Excellence (NICE)