Antenatal Antenatal carecare

Clinical Clinical GuidelineGuidelineDr .Ashraf Fouda

Damietta General Hospital

E. mail : ashraffoda@hotmail.co

m

Routine care for the healthy

pregnant woman

The following guidance is evidence based. Developed by the National Collaborating

Centre for Women’s and Children’s HealthDeveloped at October 2003, valid till

2007The grading scheme used for the

recommendations (A, B, C, D, good practice point [GPP] or NICE 2002)

Gestational age Gestational age assessment: assessment:

LMP and ultrasoundLMP and ultrasoundPregnant women should be Pregnant women should be offered an early ultrasound offered an early ultrasound

scan to determine scan to determine gestational age and to detect gestational age and to detect

multiple pregnancies. multiple pregnancies. A

Early ultrasound scanEarly ultrasound scan1.1. Ensure consistency of gestational Ensure consistency of gestational

age assessments, age assessments,

2.2. Improve the performance of mid-Improve the performance of mid-trimester serum screening for trimester serum screening for Down’s syndrome and Down’s syndrome and

3.3. Reduce the need for induction of Reduce the need for induction of labour after 41 weeks.labour after 41 weeks. A

Ideally, scans should be Ideally, scans should be performed between performed between

10 and 13 weeks and 10 and 13 weeks and crown–rump lengthcrown–rump length

measurement used to measurement used to determine gestational age. determine gestational age.

Gestational age Gestational age assessment: LMP assessment: LMP

and ultrasoundand ultrasound

GPP

Pregnant women who present Pregnant women who present at or beyond 14 weeksat or beyond 14 weeks’ gestation ’ gestation should be offered an ultrasound should be offered an ultrasound scan to estimate gestational age scan to estimate gestational age using using head circumference or head circumference or

bi-parietal diameter.bi-parietal diameter.

Gestational age Gestational age assessment: assessment: LMP and ultrasoundLMP and ultrasound

GPP

The majority of women can be The majority of women can be reassured that it reassured that it is safeis safe to continue to continue working during pregnancy. working during pregnancy.

A woman’s A woman’s occupation occupation during during pregnancy should be ascertained to pregnancy should be ascertained to identify those at increased risk identify those at increased risk through occupational exposure.through occupational exposure.

Working during Working during pregnancypregnancy

D

GPP

Nutritional supplementsNutritional supplements

Dietary supplementation with folic Dietary supplementation with folic acid, acid, before conception and up to before conception and up to 12 weeks’ gestation12 weeks’ gestation, reduces the , reduces the risk of having a baby with neural risk of having a baby with neural tube defects tube defects (anencephaly& spina bifida). (anencephaly& spina bifida).

The recommended dose is The recommended dose is 400 micrograms per day400 micrograms per day..

Folic acidFolic acid

A

Iron supplementation Iron supplementation should not should not be offered routinelybe offered routinely to all to all pregnant women. pregnant women.

It does not benefit the mother’s It does not benefit the mother’s or fetus’s health and may have or fetus’s health and may have unpleasant maternal side effects.unpleasant maternal side effects.

IronIron

A

Vitamin A supplementation Vitamin A supplementation (intake greater than 700 micrograms)(intake greater than 700 micrograms) might be teratogenic and therefore might be teratogenic and therefore it should be avoided.it should be avoided.

Liver and liver productsLiver and liver products may also may also contain high levels of vitamin A, contain high levels of vitamin A, consumption of these products should consumption of these products should also be avoidedalso be avoided..

Vitamin AVitamin A

C

There is insufficient evidence to There is insufficient evidence to evaluate the effectiveness of vitamin evaluate the effectiveness of vitamin D in pregnancy. D in pregnancy.

In the absence of evidence of In the absence of evidence of benefit, vitamin D supplementation benefit, vitamin D supplementation should not be offered routinely to should not be offered routinely to pregnant women.pregnant women.

Vitamin DVitamin D

A

Food-Food-acquired acquired infectionsinfections

Reduce the risk of Listeriosis byReduce the risk of Listeriosis by::Drinking only pasteurized or UHT Drinking only pasteurized or UHT

milkmilk Not eating mould-ripened soft cheese Not eating mould-ripened soft cheese

(there is no risk with hard cheeses (there is no risk with hard cheeses such as Cheddar, and processed such as Cheddar, and processed cheese).cheese).

Not eating uncooked or undercooked Not eating uncooked or undercooked ready-prepared meals.ready-prepared meals. D

Reduce the risk of Reduce the risk of Salmonella infection bySalmonella infection by::

Avoiding raw or partially cooked Avoiding raw or partially cooked eggs or food that may contain eggs or food that may contain them them (such as mayonnaise).(such as mayonnaise).

Avoiding raw or partially cooked Avoiding raw or partially cooked meat, especially meat, especially poultrypoultry.. D

Prescribed Prescribed medicinesmedicines

Few medicines have Few medicines have been established as been established as

safe to use in safe to use in pregnancy.pregnancy. D

Prescription medicines Prescription medicines should be used should be used as little as as little as possiblepossible during pregnancy during pregnancy and should be and should be limitedlimited to to circumstances where the circumstances where the

benefit outweighs the risk.benefit outweighs the risk.

Prescribed Prescribed medicinesmedicines

D

Exercise in Exercise in pregnancypregnancy

Beginning or continuing a Beginning or continuing a moderate coursemoderate course of of

exercise during pregnancy exercise during pregnancy is not associated with is not associated with

adverse outcomes.adverse outcomes. A

Sexual intercourse Sexual intercourse in pregnancyin pregnancy

Sexual intercourse in Sexual intercourse in pregnancy is not known pregnancy is not known

to be associated with to be associated with any adverse outcomes.any adverse outcomes.B

Alcohol in Alcohol in pregnancypregnancy

Excess alcohol has an adverse Excess alcohol has an adverse effect on the fetus. effect on the fetus.

Therefore it is suggested that Therefore it is suggested that women stop or at least limit women stop or at least limit alcohol consumption to no more alcohol consumption to no more than one standard unit per day. than one standard unit per day. C

There are specific risks of smoking during There are specific risks of smoking during pregnancy pregnancy (such as the risk of having a (such as the risk of having a baby with low birth weight and preterm).baby with low birth weight and preterm).

The benefits of quitting at any stage The benefits of quitting at any stage should be emphasized.should be emphasized.

Women who are unable to quit smoking Women who are unable to quit smoking during pregnancy should be encouraged during pregnancy should be encouraged to reduce smoking.to reduce smoking.

Smoking in Smoking in pregnancypregnancy

A

B

Cannabis use in Cannabis use in pregnancypregnancy

The direct effects of cannabis on the The direct effects of cannabis on the fetus are uncertain but may be fetus are uncertain but may be harmful. harmful.

Cannabis use is associated with Cannabis use is associated with smoking,smoking, which is known to be which is known to be harmful; therefore, women should be harmful; therefore, women should be discouraged from using cannabis discouraged from using cannabis during pregnancy.during pregnancy. C

Air travel during Air travel during pregnancypregnancy

Pregnant women should be Pregnant women should be informed that long-haul air travel informed that long-haul air travel is associated with an increased is associated with an increased risk of venous thrombosis.risk of venous thrombosis.

Wearing correctly fitted Wearing correctly fitted compression stockings is effective compression stockings is effective at reducing the risk.at reducing the risk. B

Car travel during Car travel during pregnancypregnancy

Pregnant women should be Pregnant women should be informed about the correct informed about the correct use of seat belts use of seat belts

(that is, three-point seatbelts (that is, three-point seatbelts ‘above and below the bump, ‘above and below the bump,

not over it’).not over it’). B

Traveling abroad during Traveling abroad during pregnancypregnancy

If pregnant women are If pregnant women are planning to travel abroad, planning to travel abroad,

they should discuss they should discuss considerations such as considerations such as flying, vaccinations and flying, vaccinations and

travel insurance.travel insurance. GPP

Management Management of common of common

symptoms of symptoms of pregnancypregnancy

Most cases of nausea and vomiting Most cases of nausea and vomiting in pregnancy will resolve in pregnancy will resolve spontaneously within 16 to 20 spontaneously within 16 to 20 weeks of gestation.weeks of gestation.

Nausea and vomiting are not Nausea and vomiting are not usually associated with a poor usually associated with a poor pregnancy outcome. pregnancy outcome.

Nausea and vomiting Nausea and vomiting in early pregnancy in early pregnancy

A

Nausea and vomiting in early Nausea and vomiting in early pregnancypregnancy

If a woman requests or would like to If a woman requests or would like to consider treatment, the following consider treatment, the following interventions appear to be effective in interventions appear to be effective in reducing symptoms:reducing symptoms:

non-pharmacologicalnon-pharmacological

– – gingerginger – – P6 acupressureP6 acupressure

pharmacologicalpharmacological

– – antihistamines.antihistamines. A

HeartburnHeartburnWomen who present with symptoms Women who present with symptoms

of heartburn in pregnancy should of heartburn in pregnancy should be offered information regarding be offered information regarding lifestyle and diet modification.lifestyle and diet modification.

Antacids may be offered to women Antacids may be offered to women whose heartburn remains whose heartburn remains troublesometroublesome

GPP

A

ConstipationConstipation

Women who present with Women who present with constipation in pregnancy constipation in pregnancy

should be offered information should be offered information regarding diet modification, regarding diet modification, such as bran or wheat fibre such as bran or wheat fibre

supplementation.supplementation. A

HemorrhoidsHemorrhoidsWomen should be offered Women should be offered

information concerning diet information concerning diet modification. modification.

If clinical symptoms remain If clinical symptoms remain troublesome, standard troublesome, standard hemorrhoids creamshemorrhoids creams should be should be considered.considered. GPP

Varicose veinsVaricose veinsVaricose veins are a common Varicose veins are a common

symptom of pregnancy that will symptom of pregnancy that will not cause harm andnot cause harm and

Compression stockingsCompression stockings can can improve the symptoms but will not improve the symptoms but will not prevent varicose veins from prevent varicose veins from emerging.emerging. A

Vaginal Vaginal dischargedischarge

Women should be informed Women should be informed that an increase in vaginal that an increase in vaginal

discharge is a discharge is a common common physiological changephysiological change that that occurs during pregnancy. occurs during pregnancy.

GPP

If If vaginal dischargevaginal discharge is associated is associated withwith itching, soreness, offensive itching, soreness, offensive smell or pain on passing urinesmell or pain on passing urine there may be an infective cause there may be an infective cause

and investigation should be and investigation should be considered.considered.

Vaginal Vaginal dischargedischarge

GPP

A A 1-week course of a topical 1-week course of a topical imidazoleimidazole is an effective is an effective treatment and should be treatment and should be considered for vaginal considered for vaginal

candidiasis infections in candidiasis infections in pregnant women.pregnant women.

Vaginal dischargeVaginal discharge

A

The effectiveness and safety The effectiveness and safety of of oral treatments for oral treatments for vaginal candidiasisvaginal candidiasis in in

pregnancy is uncertain and pregnancy is uncertain and these should not be offered.these should not be offered.

Vaginal dischargeVaginal discharge

GPP

BackacheBackacheWomen should be informed Women should be informed

that exercising in water, that exercising in water, massage therapy massage therapy might might help to ease backachehelp to ease backache

during pregnancy.during pregnancy. A

Clinical examination Clinical examination of pregnant womenof pregnant women

Measurement of Measurement of weight and body mass weight and body mass

index (BMI)index (BMI)Maternal weight and height Maternal weight and height

should be measured at the first should be measured at the first antenatal appointment, and the antenatal appointment, and the

woman’s woman’s BMIBMI calculated calculated (weight [kg]/height[m]2).(weight [kg]/height[m]2).

A

Repeated weighingRepeated weighing during during pregnancy should be pregnancy should be

confined toconfined to circumstances circumstances where clinical management where clinical management

is likely to be influenced.is likely to be influenced.

Measurement of Measurement of weight and body mass weight and body mass

index (BMI)index (BMI)

C

Breast Breast examinationexamination

Routine breast examination Routine breast examination during antenatal care during antenatal care is not recommendedis not recommended

for the promotion of for the promotion of postnatal breastfeeding.postnatal breastfeeding.

A

Pelvic Pelvic examinationexamination

Routine antenatal pelvic Routine antenatal pelvic examination examination does not accuratelydoes not accurately assess gestational age, nor does it assess gestational age, nor does it accurately predict preterm birth accurately predict preterm birth or cephalopelvic disproportion. or cephalopelvic disproportion.

So, it is So, it is not recommended.not recommended. B

Screening for Screening for hematological hematological

conditionsconditions

AnemiaAnemiaPregnant women should be offered Pregnant women should be offered

screening for anaemia. screening for anaemia. Screening should take place early Screening should take place early

in pregnancy in pregnancy (at the first (at the first appointment) and at 28 weeksappointment) and at 28 weeks. .

This allows enough time for This allows enough time for treatment if anaemia is detected.treatment if anaemia is detected.B

Hemoglobin levels outside the Hemoglobin levels outside the normal range for pregnancy normal range for pregnancy

(that is, 11 g/dl at first contact and (that is, 11 g/dl at first contact and 10.5 g/dl at 28 weeks)10.5 g/dl at 28 weeks) should be investigated and should be investigated and

iron supplementationiron supplementation considered considered if indicated.if indicated.

AnemiaAnemia

A

Blood grouping and Blood grouping and red cell red cell

alloantibodiesalloantibodies

Women should be offered Women should be offered testing for testing for blood group blood group and RhD statusand RhD status in early in early

pregnancy. pregnancy. BB

If a pregnant woman is RhD-If a pregnant woman is RhD-negative, offer negative, offer partner testingpartner testing

to determine whether the to determine whether the administration of anti-D administration of anti-D prophylaxis is necessary.prophylaxis is necessary.

BB

Blood grouping and Blood grouping and red cell red cell

alloantibodiesalloantibodies

It is recommended that It is recommended that routine antenatal anti-D routine antenatal anti-D prophylaxis is offered to prophylaxis is offered to

all non-sensitized all non-sensitized pregnant women who are pregnant women who are

RhD negative.RhD negative.

Blood grouping and Blood grouping and red cell red cell

alloantibodiesalloantibodies

NICE 2002

Women should be screened for Women should be screened for atypical red cell alloantibodies atypical red cell alloantibodies in early pregnancy and again in early pregnancy and again at 28 weeks regardless of their at 28 weeks regardless of their

RhD status.RhD status.

Blood grouping and Blood grouping and red red cell alloantibodiescell alloantibodies

D

Pregnant women with clinically Pregnant women with clinically significant atypical red cell significant atypical red cell

alloantibodies should be offered alloantibodies should be offered referral to a referral to a specialist centrespecialist centre for for

further investigation and advice on further investigation and advice on subsequent antenatal management.subsequent antenatal management.

Blood grouping and Blood grouping and red red cell alloantibodiescell alloantibodies

GPP

Screening for Screening for fetal fetal

anomaliesanomalies

Screening for Screening for structural structural

anomaliesanomaliesPregnant women should be offered an Pregnant women should be offered an

ultrasound scanultrasound scan to screen for structural anomalies, to screen for structural anomalies, ideally between 18 and 20 weeks’ ideally between 18 and 20 weeks’

gestationgestation, by an appropriately trained , by an appropriately trained sonographer and with equipment of sonographer and with equipment of

an appropriate standard.an appropriate standard. A

Screening for Down’s Screening for Down’s syndromesyndrome

Pregnant women should be Pregnant women should be offered screening for Down’s offered screening for Down’s syndrome with a test which syndrome with a test which

provides the current standard provides the current standard of a of a detection rate above 60% detection rate above 60% and a false-positive rate of less and a false-positive rate of less

than 5%. than 5%. B

The following tests meet this standard:The following tests meet this standard:from 11 to 14 weeksfrom 11 to 14 weeks– – nuchal translucency nuchal translucency (NT)(NT)– – the combined test the combined test (NT, hCG and PAPP-A)(NT, hCG and PAPP-A)from 14 to 20 weeksfrom 14 to 20 weeks– – the triple test the triple test (hCG, AFP and uE3)(hCG, AFP and uE3)– – the quadruple test the quadruple test (hCG, AFP, uE3, (hCG, AFP, uE3,

inhibin A)inhibin A) B

Screening Screening for for

infectionsinfections

Asymptomatic Asymptomatic bacteriuriabacteriuria

Pregnant women Pregnant women should be offeredshould be offered routine screeningroutine screening for asymptomatic for asymptomatic bacteriuria by midstream urine bacteriuria by midstream urine culture early in pregnancy. culture early in pregnancy.

Identification and treatment of Identification and treatment of asymptomatic bacteriuria asymptomatic bacteriuria reduces the reduces the risk of preterm birth.risk of preterm birth. A

Asymptomatic Asymptomatic bacterial vaginosisbacterial vaginosis

Pregnant women should Pregnant women should not be offerednot be offered routine screening for bacterial routine screening for bacterial vaginosis because the evidence vaginosis because the evidence

suggests that the identification and suggests that the identification and treatment of treatment of asymptomatic bacterial asymptomatic bacterial vaginosisvaginosis does not lower the risk for does not lower the risk for

preterm birth and other adverse preterm birth and other adverse reproductive outcomes.reproductive outcomes. A

Chlamydia Chlamydia trachomatistrachomatis

Pregnant women should Pregnant women should not be offered routine screeningnot be offered routine screening

for asymptomatic chlamydia for asymptomatic chlamydia because there is insufficient because there is insufficient

evidence on its effectiveness and evidence on its effectiveness and cost effectiveness. cost effectiveness.

C

CytomegaloviCytomegalovirusrus

The available evidence does The available evidence does not support routine not support routine

cytomegalovirus screeningcytomegalovirus screening in pregnant women and it in pregnant women and it

should not be offered.should not be offered.B

Hepatitis B virusHepatitis B virusSerological screening for hepatitis Serological screening for hepatitis

B virus B virus should be offeredshould be offered to to pregnant women pregnant women

So that effective postnatal So that effective postnatal intervention can be offered to intervention can be offered to infected women to decrease the risk infected women to decrease the risk of mother-to-child-transmission.of mother-to-child-transmission. A

Hepatitis C Hepatitis C virusvirus

Pregnant women should Pregnant women should not be offered routine screeningnot be offered routine screening

for hepatitis C virus because for hepatitis C virus because there is there is insufficient evidenceinsufficient evidence on on

its effectiveness and cost its effectiveness and cost effectiveness.effectiveness. C

HIV infectionHIV infectionPregnant women Pregnant women should be offered should be offered

screening for HIV infection earlyscreening for HIV infection early in antenatal care because in antenatal care because

appropriate antenatal appropriate antenatal interventions can reduce interventions can reduce

mother-to-child transmission of mother-to-child transmission of HIV infection.HIV infection. D

RubellaRubellaRubella-susceptibility screening Rubella-susceptibility screening should should

be offered early in antenatal carebe offered early in antenatal care to to identify women at risk of contracting identify women at risk of contracting

rubella infection and to enable rubella infection and to enable vaccination in the postnatal period for vaccination in the postnatal period for the protection of future pregnancies.the protection of future pregnancies.

B

Streptococcus Streptococcus group Bgroup B

Pregnant women Pregnant women should not be should not be offered routine antenatal offered routine antenatal

screeningscreening for group B for group B streptococcus (GBS) streptococcus (GBS)

because evidence of its clinical because evidence of its clinical effectiveness and cost effectiveness effectiveness and cost effectiveness

remains uncertain.remains uncertain. C

SyphilisSyphilisScreening for syphilis Screening for syphilis should be should be offered to all pregnant women at offered to all pregnant women at an early stage in antenatal carean early stage in antenatal care because treatment of because treatment of

syphilis is beneficial to the syphilis is beneficial to the mother and fetus.mother and fetus. B

ToxoplasmosisToxoplasmosisRoutineRoutine antenatal serological antenatal serological

screening for toxoplasmosis screening for toxoplasmosis should not be offeredshould not be offered because because the harms of screening may the harms of screening may

outweigh the potential outweigh the potential benefits.benefits. B

Pregnant women should be informed of primary Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis prevention measures to avoid toxoplasmosis

infection, such as:infection, such as:1.1. Washing hands before handling foodWashing hands before handling food2.2. Thoroughly washing all fruit and Thoroughly washing all fruit and

vegetables, before eatingvegetables, before eating3.3. Thoroughly cooking raw meats Thoroughly cooking raw meats 4.4. Wearing gloves and thoroughly washing Wearing gloves and thoroughly washing

hands after handling soil and gardeninghands after handling soil and gardening5.5. Avoiding cat faeces in cat litter or in soil.Avoiding cat faeces in cat litter or in soil.

ToxoplasmosisToxoplasmosis

C

Screening for Screening for

clinical conditionsclinical conditions

Gestational diabetes Gestational diabetes mellitusmellitus

The evidence The evidence does not does not support routine screeningsupport routine screening for gestational diabetes for gestational diabetes mellitus and therefore mellitus and therefore

It should not be offered.It should not be offered. B

Pre-eclampsiaPre-eclampsiaAt first contact a woman’s At first contact a woman’s level of risk for pre-eclampsialevel of risk for pre-eclampsia should be evaluated should be evaluated

so that a plan for her so that a plan for her subsequent schedule of subsequent schedule of

antenatal appointments can antenatal appointments can be formulated.be formulated. C

Developing pre-eclampsia during a Developing pre-eclampsia during a pregnancy is increased in women whopregnancy is increased in women who::

1.1. are nulliparousare nulliparous

2.2. are aged are aged 4040 or older or older

3.3. have a family history of pre-eclampsia have a family history of pre-eclampsia

4.4. have a prior history of pre-eclampsiahave a prior history of pre-eclampsia

5.5. have a body mass index have a body mass index (BMI)(BMI) at or above at or above 3535 at first contactat first contact

6.6. have a multiple pregnancy or pre-existing have a multiple pregnancy or pre-existing vascular disease vascular disease (for example, hypertension or (for example, hypertension or diabetes).diabetes).

C

Whenever blood pressure is Whenever blood pressure is measured in pregnancy a measured in pregnancy a urine sample should be urine sample should be

tested at the same time for tested at the same time for proteinuria.proteinuria.

Pre-Pre-eclampsiaeclampsia

C

Pregnant women should be informed of the Pregnant women should be informed of the symptoms of advanced pre-eclampsia symptoms of advanced pre-eclampsia because these may be associated with poorer because these may be associated with poorer pregnancy outcomes for the mother or baby.pregnancy outcomes for the mother or baby.

Symptoms include headache; problems with Symptoms include headache; problems with vision, such as blurring or flashing before the vision, such as blurring or flashing before the eyes; bad pain just below the ribs; vomiting eyes; bad pain just below the ribs; vomiting and sudden swelling of face, hands or feet.and sudden swelling of face, hands or feet.

Pre-eclampsiaPre-eclampsia

D

Preterm birthPreterm birthRoutine vaginal examination Routine vaginal examination

to assess the cervix to assess the cervix is not an effectiveis not an effective method method

of predicting preterm birth of predicting preterm birth and should not be offered.and should not be offered.

A

Although Although cervical shorteningcervical shortening identified identified by Transvaginal ultrasound and by Transvaginal ultrasound and

increased levels of fetal fibronectinincreased levels of fetal fibronectin are associated with an increased risk are associated with an increased risk for preterm birth, for preterm birth, the evidence does not indicate that the evidence does not indicate that

this information improves outcomesthis information improves outcomes..

Preterm birthPreterm birth

B

Neither routine antenatal cervical Neither routine antenatal cervical assessment by transvaginal assessment by transvaginal

ultrasound nor the measurement ultrasound nor the measurement of fetal fibronectinof fetal fibronectin

should be used to predict preterm should be used to predict preterm birth in birth in healthyhealthy pregnant women. pregnant women.

Preterm birthPreterm birth

B

Placenta praeviaPlacenta praevia Because Because most low-lying placentas most low-lying placentas

detected at a 20-week anomaly scandetected at a 20-week anomaly scan will will resolve by the time the baby is born, resolve by the time the baby is born, only a woman whose only a woman whose placenta extends placenta extends over the internal cervical osover the internal cervical os should be should be offered another Tran abdominal scan at offered another Tran abdominal scan at 36 weeks. 36 weeks.

If the transabdominal scan is unclear, If the transabdominal scan is unclear, a a transvaginal scantransvaginal scan should be offered. should be offered.

C

Fetal growth Fetal growth and well-and well-

beingbeing

Abdominal palpation Abdominal palpation for fetal for fetal presentationpresentation

Fetal presentation should be Fetal presentation should be assessed by assessed by abdominal abdominal

palpation at 36 weeks or laterpalpation at 36 weeks or later, , when presentation is likely to when presentation is likely to

influence the plans for the influence the plans for the birth. birth. C

RoutineRoutine assessment of presentation by assessment of presentation by abdominal palpation abdominal palpation should not be offered before 36 weeksshould not be offered before 36 weeks because it is because it is not always not always accurateaccurate and may be and may be uncomfortableuncomfortable..

Suspected fetal malpresentation Suspected fetal malpresentation should be confirmed by should be confirmed by ultrasoundultrasound..

Abdominal palpation Abdominal palpation for fetal for fetal presentationpresentation

C

Measurement of Measurement of symphysis–fundal symphysis–fundal

distancedistancePregnant women should be offered Pregnant women should be offered

estimation of estimation of fetal sizefetal size at each antenatal at each antenatal appointment to detect appointment to detect small- or large-for small- or large-for gestational- agegestational- age infants. infants.

Symphysis–fundal height should be Symphysis–fundal height should be measured and plotted at each antenatal measured and plotted at each antenatal appointment.appointment.

A

Routine Routine monitoring of monitoring of fetal movementsfetal movements

Routine formal Routine formal fetal-movement fetal-movement counting counting

should not be offered.should not be offered.A

Auscultation of Auscultation of fetal heartfetal heart

Auscultation of the fetal heart Auscultation of the fetal heart may confirm that the fetus is may confirm that the fetus is alive but is unlikely alive but is unlikely to have to have any predictive valueany predictive value and routine listening is and routine listening is

therefore not recommendedtherefore not recommended. .

D

When requestedWhen requested by the by the mother, auscultation mother, auscultation of the fetal heart may of the fetal heart may provide provide reassurancereassurance..

Auscultation of Auscultation of fetal heartfetal heart

D

CardiotocograpCardiotocographyhyThe evidence The evidence does notdoes not support the support the

routine use of antenatal electronic routine use of antenatal electronic fetal heart rate monitoringfetal heart rate monitoring

(cardiotocography) for fetal (cardiotocography) for fetal assessment in women with an assessment in women with an uncomplicated pregnancy and uncomplicated pregnancy and

therefore therefore it should not be offeredit should not be offered..A

Ultrasound Ultrasound assessment assessment in the third in the third

trimestertrimesterThe evidence The evidence does not support does not support the routine use of ultrasound the routine use of ultrasound

scanning after 24 weeksscanning after 24 weeks’ ’ gestation and therefore it gestation and therefore it

should not be offered.should not be offered. A

Umbilical artery Umbilical artery Doppler ultrasoundDoppler ultrasound

The use of The use of umbilical arteryumbilical artery Doppler ultrasound for the Doppler ultrasound for the prediction of prediction of fetal growth fetal growth restrictionrestriction should not be should not be

offered routinelyoffered routinely.. A

The use of The use of uterine arteryuterine artery Doppler ultrasound for the Doppler ultrasound for the prediction of pre eclampsiaprediction of pre eclampsia

should should not be offered not be offered routinely.routinely.

Uterine artery Uterine artery Doppler ultrasoundDoppler ultrasound

B

Pregnancy after 41 Pregnancy after 41 weeksweeks

Prior to formal induction of Prior to formal induction of labour, women should be offered a labour, women should be offered a vaginal examination for membrane vaginal examination for membrane sweeping.sweeping.

Women with uncomplicated Women with uncomplicated pregnancies should be offered pregnancies should be offered induction of labour beyond 41 induction of labour beyond 41 weeks.weeks.

A

Breech presentation at Breech presentation at termterm All women who have an uncomplicated All women who have an uncomplicated

singleton breech pregnancy at singleton breech pregnancy at 36 weeks’ 36 weeks’ gestation should be offered external cephalic gestation should be offered external cephalic version (ECV).version (ECV).

Exceptions include :Exceptions include :1.1. women in labour, and women in labour, and 2.2. a uterine scar or abnormality; a uterine scar or abnormality; 3.3. fetal compromise; fetal compromise; 4.4. ruptured membranes; ruptured membranes; 5.5. vaginal bleeding.vaginal bleeding.

A