Care should be centred on the pregnant woman; the aim should be to keep her fully informed on the progress of her pregnancy and to provide her with evidence-based information and support to make informed decisions.1 She should initially be given:

Assessment of gestational age should be based on an early ultrasound scan rather than the last menstrual period. Such scans should be offered to all women and help to ensure:

• Consistency of gestational age assessments.

• Improved accuracy of Down's screening assessment.

• Sensible decisions on induction of labour after 41 weeks.

Further advice to patients

Employment

Advise on maternity rights and benefits and reassure patient on how safe it is to continue working in pregnancy. Check occupation for exposure to harmful agents.

Nutrition

In healthy women on a normal diet, advice on eating 5 portions of fruit and vegetables per day and drinking plenty of milk to raise stores of vitamins, iron and calcium is reasonable.
Because of the dangers of toxoplasmosis and listeriosis, women should avoid:

• Uncooked meat, fish and eggs

• Milk that has not been pasteurised

• Soft cheeses

• All unwashed fruit and vegetables (they should be washed)

Vegetarians, and especially vegans, are at risk of various nutritional deficiencies and may need to be referred to a dietitian.
Women should be cautioned to avoid many herbal preparations and teas; their use and safety in pregnancy has not been studied.

Folic acid

Supplementation with folic acid is one of the most significant interventions available. 400 mcg/day for all women has been shown to reduce the incidence of neural tube defects (NTD), such as spina bifida, by 72%.2
Women who have already given birth to a child with an NTD, or who are at a higher risk should be prescribed 5 mg/day. Higher risk of NTD is associated with coeliac disease, family history of NTD or anti-epileptic medication. This dose is also recommended for women with diabetes (types 1 or 2)3 and sickle cell anaemia.4
This is given for at least one month prior to conception and three months afterwards.
Diet alone does not reliably supply an adequate amount of folic acid for this effect.
It can be prescribed or bought over-the-counter (OTC) cheaply.

Vitamin D

Adequate vitamin D stores during pregnancy and breastfeeding are important for the health of both mother and baby.1
All women may choose to take vitamin D supplements (10 μg /day), but this is particularly important in the following groups:

• Housebound women or those who have limited exposure to sunlight, such as women who usually remain covered when outdoors

• South Asian, African, Caribbean or Middle Eastern family origin.

• Those with a diet particularly low in vitamin D. Good sources of vitamin D are oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal.

• Women with a pre-pregnancy BMI > 30 kg/m².

Medication

Advise to use as few medicines as possible during pregnancy and only when benefit outweighs risk. This includes OTC medication and complementary therapies, as few products have been shown to be definitely safe during pregnancy.

Lifestyle

Nausea and vomiting of pregnancy generally resolve by 16-20 weeks' gestation; ginger and P6 acupressure may be beneficial.5 Antihistamines have also been used. Heartburn may be alleviated by taking small meals and raising the head of the bed. It may need antacids.

Exercise:
Women who exercise regularly should be advised to continue to do so. Those who are inactive should start a gentle programme of regular exercise. Moderate exercise has not been shown to cause any harm, but patient should be warned of the dangers of highly energetic and contact sports that would risk damage to the abdomen, falls or excessive joint stress. Strenuous exercise in the first 3 months of pregnancy is inadvisable, because of the possible risks to the fetus of overheating. Similarly, saunas and hot tubs should be avoided.
Scuba diving should be avoided as it can cause fetal birth defects and fetal decompression disease.

Sexual intercourse:
This has not been shown to cause any harm during pregnancy. It is advisable to avoid it if there is evidence of pre-term rupture of membranes.

Alcohol:
High levels of alcohol consumption during pregnancy result in the fetal alcohol syndrome (FAS). There are various components including growth retardation, mental retardation, facial anomalies and behavioural problems.6
FAS is seen in approximately 33% of babies born to mothers who drink 18 units/day.
There is no clear safe level of consumption. The safest approach may be to avoid any alcohol intake during pregnancy, although there is no evidence that one or two drinks, once or twice a week is likely to harm the fetus.6

Smoking:
Smoking in pregnancy is associated with a large number of adverse effects in pregnancy including7:

• Intra-uterine growth retardation

• Miscarriage and stillbirth

• Premature delivery

• Placental problems

Counselling on smoking cessation is essential for women who intend to become pregnant and various forms of help are available.8,9
There is little information on the use of nicotine replacement therapy (NRT) in pregnancy, but smoking gives a greater dose of nicotine and also exposes mother and fetus to other toxins. It is likely to be safer than smoking in mothers for whom non-pharmacological interventions have failed. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription. Advise pregnant women using nicotine patches to remove them before going to bed.

Illicit drug use:
The number of women misusing drugs has increased considerably in the past 30 years, and many are in their child-bearing years. Though pregnancy may act as a catalyst for change and present a 'window of opportunity', drug misusers may not use general health services until late into pregnancy and this increases the health risks for both the mother and child.

• A multidisciplinary approach is essential.10 Most localities will have a clearly defined drug dependency service with a readily accessible entry point.

• Cocaine use in pregnancy is particularly serious and there is no substitute. It has been associated with spontaneous abortion, placental abruption, premature birth, low birthweight and sudden infant death syndrome. There is conflicting evidence regarding fetal abnormalities.11

• Opiate use is associated with increased incidence of intra-uterine growth retardation and preterm delivery. This contributes to an increased rate of low birthweight and perinatal mortality.

• Women addicted to heroin who wish to become pregnant should be urged to enter a detoxification programme before conception and, if not, then at least stabilised on methadone.

• HIV and Hepatitis B screening is carried out in all pregnant women in the UK12, but is especially important in known IV drug users. Hepatitis C screening is also recommended in this group.

• The use of cannabis may be harmful to the fetus and is also associated with smoking and should be discouraged.

Travel:
Flying is associated with increased risk of DVT and not known if further increased in pregnancy. Use of compression hosiery reduces the risk. Also discuss vaccinations and travel insurance if travelling abroad.
Advise on proper use of seat belts for car travel, with belts above and below bump rather than over it.

Antenatal appointments

The following number of appointments is generally recommended in uncomplicated pregnancies1:
Nulliparous women - 10
Parous women - 7
Information about the timing and function of these appointments should be given to the woman in writing with the chance to discuss them with her doctor or midwife. Appointments should have a focus and structure and include routine tests where possible.

Appointment schedule

All appointments should include measuring BP and testing urine for proteinuria. Pre-eclampsia occurs more frequently in:

• Those with a previous history

• The nulliparous

• Multiple pregnancies

• Those aged >40

• Those with a close family history

• Those where BMI >35 at first presentation

• Those with pre-existing vascular disease, e.g. hypertension or diabetes

They should also be used as an opportunity to give information and allow patient to ask questions and discuss any topics concerning her. Domestic violence is a subject that pregnant women should be encouraged to discuss openly.

First (booking) appointment

Should be before 12 weeks of pregnancy. May need to be two appointments because of volume of information required to be imparted. All information should initially be offered verbally and backed up in writing with an opportunity to discuss and ask questions.

• Should cover lifestyle topics such as diet, alcohol, smoking, exercises etc; together with antenatal care services available and maternity benefits.
  Initial measurement of weight, BMI and BP. Repeated weighing is only appropriate in later pregnancy where it is likely to affect management.

• Clinician needs to provide enough information to make an informed decision about undergoing available screening tests.
  Offer screening of mother for:

  • Anaemia

  • Red cell allo-antibodies

  • Hepatitis B virus

  • HIV

  • Rubella susceptibility

  • Syphilis

  • Asymptomatic bacteriuria

  Arrange as agreed. There is no evidence to support routine screening for gestational diabetes.1

• Offer early scan for assessment of gestational age, preferably performed at 10-13 weeks, measuring the crown-rump length. Alternatively, at or after 14 weeks, measure bi-parietal diameter, or circumference of head.

• Offer screening of fetus for Down's syndrome. NB: ensure patient is aware that she is not obliged to have Down's screening tests and that they have (depending on test) 60% detection rate and 5% false positive rate. Screening may involve nuchal translucency on ultrasound before 14 weeks or serum tests at 14-20 weeks, e.g. double, triple, quadruple.

• Offer screening of fetus for other structural anomalies by ultrasound scan at 20 weeks, if available.

• Need to identify those women who may require extra care and create a plan for this.13 Ask about any current or previous significant medical or psychiatric illnesses. Use of the Edinburgh PND score to screen antenatally is NOT appropriate.
  Routine breast and pelvic examinations are not recommended, as not shown to give any benefits. Where appropriate, the question of genital mutilation should be raised sensitively.

Further appointments

• 16 weeks: this appointment should be used to review the results of earlier tests, discuss them with the patient and if necessary institute a changed pattern of antenatal care having identified those women who require additional care. Consider offering oral iron to women with a haemoglobin <11g/dl.

• 18-20 weeks: this appointment is for women who have agreed to a test for fetal structural anomalies. If the placenta is found to cover the internal cervical os, the scan should be repeated at 36 weeks.

• 25 weeks: this appointment is for nulliparous women and, as well as routine procedures, e.g. BP check, proteinuria screening, should include measurement and plotting of symphysis-fundal height.
  
  NB: All appointments from this point should routinely include measurement and plotting of symphysis-fundal height.
  
  

• 28 weeks: this appointment is for all pregnant women and, in addition to routine procedures, they should be offered another opportunity to screen for anaemia and atypical red cell allo-antibodies, investigate and treat haemoglobin <10.5 g/dl and offer anti-D prophylaxis for rhesus-negative women.

• 31 weeks: this appointment is for nulliparous women and, as well as routine procedures, it should include a review of screening tests performed at 28 weeks with reassessment of care needs and identification of those that need extra care.

• 36 weeks: this appointment is for all pregnant women and, in addition to routine procedures, should allow for checking of the position of the fetus with external cephalic version offered to women with a breech presentation. Where previous scan showed the placenta covering the internal cervical os, this should be reviewed.

• 38 weeks: this appointment is for all pregnant women for all routine procedures to be performed.

• 40 weeks: this appointment is for all pregnant women for all routine procedures to be performed.

• 41 weeks: this appointment is for all pregnant women who are not yet given birth and, in addition to all routine procedures, patient should be offered a membrane sweep and/or induction of labour.