Powys Teaching Local Health Board
Directorate: Women’s and Children’s
Author: Lewis, Owen, Revell / Title: Antenatal care Guidelines
Code: PtHB MAT 001

ANTENATAL CARE GUIDELINES

Document Code / Date / Version Number / Planned Review Date
PtLHB/
MAT 001 / Aug 2006
Jan 2009
Jan 2012 / 1st Issue
2nd Issue. Reviewed & updated with NICE
antenatal care guidelines 2008
3rd Issue Reviewed and minor alterations/updating / Aug 2009
Jan 2012
Jan 2015
Document Owner / Approved by / Date
Women’s and Children’s Directorate / Women’s and children’s Directorate
Clinical Effectiveness / 22/12/2011
16/04/12
Document Type / Guideline

Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys

Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board

ANTENATAL CARE GUIDELINES

Contents / Page
Validation Form / 3
Equality Assessment / 4
Relevant to / 5
Purpose / 5
Definitions / 5
Responsibilities / 5
Process / 5
References / 5
Appendices
APPENDIX (Recommended Pattern of Care For High Risk Women) / 18

For Reviewed / Updated Policies Only:

Relevant Changes – / Date
3rd Issue Reviewed and minor alterations/updating / 16/12/12

VALIDATION & RATIFICATION

Title: Antenatal care guidelines
Authors: Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys.
Directorate: Women and Children’s
Reviewed/ Updated by: Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys, Denise Revell Integrated Midwife
Approved for submission by: Cate Langley Date: 20/12/11
Evidence Base
Are there national guidelines, policies, legislation or standards relating to this subject area?
If yes, please include below:
National Institute of Clinical Excellence (2008) Antenatal care: Routine
care for the healthy pregnant woman. NICE: London.
National Institute of Clinical Excellence (2010) Hypertension in Pregnancy: The management of hypertensive disorders during pregnancy. NICE: London
National Institute of Clinical Excellence (2008) Induction of Labour.
NICE: London
National Institute of Clinical Excellence (2008) Diabetes in Pregnancy.
NICE: London
Nursing and Midwifery Council (2010) Midwives rules and standards. NMC. London
If No, please provide information on the evidence/expert opinion upon which the policy has been based.
CONSULTATION
Please list the groups, specialists or individuals involved in the development & consultation process:
Name / Date
Powys Midwives / 16/12/11
Supervisor of Midwives – Powys / 16/12/11
Practice Development Midwife / 16/12/11
Lead Midwives & Head of Midwifery / 16/12/11
Health Visitors and School Nursing team / 16/12/11
Women’s and Children’s Directorate Departmental leads, Safeguarding team, Andrew Cresswell / 16/12/11
Please insert the name of the Directorate/ Departmental/Discipline Committee or Group that has approved this policy/procedure/guidelines/protocol
Name / Date
Women’s & Children’s Directorate / 22/12/11
Clinical Effectiveness / 16/04/12
Implications: Please state any training implications as a result of implementing the policy / procedure.
No Additional Training required implementing this guideline.
Please state any resource implications associated with the implementation.
No Additional Resources required to implement this guideline
Please state any other implications which may arise from the implementation of this policy/procedure. Nil
For Completion by Quality & Safety Unit
Checked by: / Date:
Submitted to CEC: / Date:

Equality Assessment Statement

Equality statement
No impact / Adverse / Differential / Positive / Comments
Age / X
Disability / X
Gender / X / Woman focused midwifery policy
Race / X
Religion/ Belief / x
Sexual Orientation / X
Welsh Language / X
Human Rights / X

Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all.

Risk Assessment

Are there any new or additional risks arising from the implementation of this policy?
None
Do you believe that they are adequately controlled?
N/A.

Relevant to:

Local guideline for all midwives working in Powys.

Purpose:

The overall aim must be to ensure safe and effective care is provided to

mother and baby, whilst allowing women to make an informed choice from the type of antenatal care options available to them. Also, to initiate and implement the referral of the mother to a District General Hospital (DGH), where any deviation from normal occurs.

Responsibilities

All Midwives working within Powys hold a recognised midwifery

qualification, no additional qualifications are required to carry out this

policy. Midwives will be required to attend yearly obstetric emergency

drills as part of their midwifery updates.

Monitoring

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the Datix reporting system.

Process

GUIDELINES FOR THE PATTERN OF ANTENATAL CARE

Introduction

The pattern of antenatal care should be based on the recommendations of

NICE (2008) for women with uncomplicated pregnancies. Midwives

should view this pattern of antenatal visits as a minimum baseline with

any other visits arranged according to individual women’s needs and in

negotiation with the woman.

Each antenatal appointment should be structured and have a focused

content. Women should be the focus of all care. Care should be accessible, promote informed choice and continuity of care. [DOH 2007,

WG 2011]

A small group of midwifery carers with whom the woman feels

comfortable should provide antenatal care. There should be continuity of

care throughout the antenatal period (NICE 2008). All information given

to women should be supported by The Pregnancy Book, (DOH 2007b) and All Wales Antenatal Screening Guidelines (ANSW 2010).

The woman and her named midwife should discuss a plan for antenatal care, and a joint decision made as to where and by whom this care will be delivered. The location of a woman’s care should enable her to feel comfortable discussing or disclosing information about herself or her health and/or social circumstances, and takes into account individual, family and work commitments. As a minimum, the booking and 36-week visit should ideally be at home in order to complete a full risk assessment. The location of all visits should be documented in the woman’s handheld notes.

Action

Recommended Pattern of Care for Low Risk Women

Prior to the booking visit the woman should receive information on folic

acid, food hygiene, lifestyle advice and Antenatal Screening Wales. (NICE

2008)

  • Booking Visit, before 10 weeks (NICE 2008) at home. This may be split into two appointments with one taking place in an environment suitable to measure maternal height and weight. Body Mass index (BMI) recorded, and venous thrombosis (VTE) assessment should be documented.
  • Ultrasound scan – dating at 10-12 weeks gestation [NICE 2008], ideally once booking visit is completed by midwife (unless requested otherwise by the woman).Midwives should be aware that some aspects of this USS are improved if carried out after 11 weeks especially in women with a raised BMI. If USS is carried out between 10-11 weeks recall may be necessary.
  • Anomaly Scan offered at 18-20weeks.
  • Antenatal appointments at 16, 25, 28, 31, 34, 36 (at home), 38, 40 and 41 weeks for nulliparous women.
  • Antenatal appointments at 16, 28, 34, 36 (at home), 38, 41 weeks for parous women
  • During the flu vaccination season midwives should advise women to contact their GP for the vaccine regardless of their gestation.

Recommended Pattern of Care For High Risk Women (See Appendix)

Any woman identified at booking as requiring consultant led care, or who at any stage during her antenatal care, is referred to a consultant and then receives the majority of her remaining antenatal care from the consultant, still requires support and care from her local midwifery team.

On occasions these visits may not be to provide routine antenatal care, but to provide extra support and advice relating to the woman’s circumstances. Pattern and content of antenatal visits should be planned with the woman and consultant obstetrician.

Schedule of Appointments and Antenatal care

In an uncomplicated pregnancy there should be 10 appointments for nulliparous women and 7 appointments for parous women. (NICE 2008)

First appointment (Before 10 weeks)

  • Because of the large volume of information needed in early pregnancy, the ‘booking’ visit may require two appointments. All women, where possible, should have received prior to their first midwife appointment their handheld notes, the All Wales information pack on Antenatal Screening, information on smoking cessation, and information on maternity services in Powys and how to contact a midwife.

.

  • Women should be aware that partners are welcomed at all visits.
  • Give information, with an opportunity to discuss issues and ask questions. Verbal information must be supported by written

information using The Pregnancy Book (DOH 2007).

  • Topics to include;

 Reasons for antenatal care and detection of obstetric complications e.g. Pre-eclampsia.

 Diet and lifestyle considerations.

 Safety in the home and workplace.

 Maternity benefits.

 Exercise, relaxation and preparation for Parenthood classes.

 Correct wearing of seat belts.

 Basic first aid measures, especially for women with medical conditions such as epilepsy.

 Benefits of breastfeeding.

 Sufficient information to enable informed decision making about screening tests.

 FW8

  • Domestic violence - if the woman is alone midwives should proceed to routine enquiry. If not this should be completed at the first appointment when the woman attends alone, and the reason why not completed documented on the DA1 form.
  • Past pregnancy, birth and postnatal experiences.
  • Women should be asked about their mental health and any previous issues identified. (Refer to Guideline for The Management of Antenatal and Postnatal Mental Health).
  • Identify women who may require additional care and plan pattern of care for the pregnancy.
  • Offer routine screening for blood group and Rh (D) status, anaemia, antibodies, Hepatitis B, HIV, rubella, syphilis and offer sickle cell and thalassemmia in line with ANSW guidelines. (Routine screening for chicken pox, toxoplasmosis and strep B is not indicated)
  • Offer screening for asymptomatic bacteruria
  • Offer screening for Down’s syndrome.
  • Offer early ultrasound scan for gestational age assessment.
  • Offer ultrasound for structural anomalies (20 weeks).
  • Measure BMI, blood pressure and test urine for proteinuria.
  • Complete Venous Thrombo Embolism Risk Assessment (1000 lives+)
  • Determine risk factors for gestational diabetes. NICE [2008]do not recommend routine blood glucose monitoring.
  • Determine risk factors for pre-eclampsia.
  • Advise women to contact a midwife immediately if suffering from any of the following symptoms- severe headache, problems with vision such as blurring or flashing, severe pain just below the ribs, vomiting or sudden swelling of face, hands or feet. (NICE 2010)
  • Women younger than 25 should be informed of the prevalence of

chlamydia in their age group. Routine screening is not

recommended but details should be given of National Chlamydia

screening programmes. (NICE 2008)

  • Women should be specifically asked key questions in relation to their emotional wellbeing and feelings of depression. (NICE 2008)
  • Women should be informed of the importance of maintaining

Vitamin D stores for the health and well being of themselves and

their babies, during pregnancy and while breastfeeding. Women

may choose to take 10 micrograms of vitamin. D per day as found

in the Healthy Start vitamin supplement. (NICE 2008)

16 Weeks

  • Check Estimated Date of Delivery (EDD) with findings from ultrasound scan, print out customised growth chart and add to handheld notes.
  • Measure blood pressure and test urine for proteinuria.
  • Downs syndrome screening if requested.
  • Discuss and record blood results (enclosing hard copy) in the woman’s pregnancy hand held records.
  • Discuss Anti-d routine prophylaxis with all women identified as Rhesus negative.
  • Give information regarding antenatal education being available as a four prong approach: one to one, local groups, road shows and specific active birth workshops.
  • Review/revise management plan.

In the event of any of the screening tests highlighting a need for a change

in the planned pattern of care, the midwife should contact the woman and

discuss the implications.

These include:

  • Hb of less than 11g/dl (Further investigation may be necessary. Iron supplementation may be required.)
  • High-risk Downs screening.
  • Anomalies on scan.
  • Multiple pregnancy.

25 Weeks (Nulliparous Women)

  • Measure blood pressure and test urine for proteinuria
  • Measure and plot symphysis-fundal height.[NICE 2008]
  • Discuss and record blood results (include hard copy) and fetal anomaly scan results in the woman’s hand held notes.
  • Ensure a repeat scan has been made for women with low lying placenta, in line with DGH guidance.
  • Sign Mat B1 (if required), and offer breastfeeding DVD
  • Review/revise management plan.

28 Weeks

  • Measure blood pressure and test urine for proteinuria.
  • Measure and plot symphysis-fundal height.
  • Offer blood tests for Rh (D) antibodies and anaemia.
  • Investigate Hb below 10.5 g/dl, and consider supplementation if necessary.
  • Offer anti-D prophylaxis to women who are rhesus D-negative. (Please refer to Anti D Guideline)
  • Review risk assessments, mental health questions, and repeat DA1 if woman is alone. (If woman is not alone document reason why not asked on DA1)
  • Offer breastfeeding DVD to parous women.
  • Review/revise management plan.

31 Weeks (Nulliparous Women)

  • Measure blood pressure and test urine for proteinuria.
  • Measure and plot symphysis-fundal height.
  • Discuss and record blood results (include hard copy) in woman’s hand held notes.
  • Ask about fetal movements and document in hand held notes. Women are not required to count movements but should report to a midwife if they feel that the normal pattern of movements has changed or reduced. A referral to a DGH for additional monitoring should then be offered and arranged.
  • Review/revise management plan.

34 Weeks

  • Measure blood pressure and test urine for proteinuria.
  • Measure and plot symphysis-fundal height.
  • Discuss and record blood tests taken at 28 weeks if not already done so.
  • Discuss pattern of fetal movements.
  • Review/revise management plan.

36 Weeks

  • Measure blood pressure and test urine for proteinuria.
  • Measure and plot symphysis-fundal height.
  • Discuss pattern of fetal movements.
  • For women whose baby is in the breech position, discuss and arrange an appointment for follow up ultrasound scan and possible external cephalic version with the consultant obstetrician.
  • Review repeat ultrasound scan if low lying placenta.
  • If receiving iron therapy recheck Hb.
  • Discuss and document plans for labour, birth and infant feeding.
  • Give women information on All Wales Normal Labour pathway.
  • Discuss and give women NICE Quick Reference Guide to Postnatal Care and Powys Postnatal Care Pathway.
  • Give information about postnatal self care and emotional well being, including baby blues and postnatal depression (NICE 2008).
  • Discuss care of the newborn, information about the management of breastfeeding, vitamin K prophylaxis, and newborn screening tests.
  • Review risk assessments, mental health questions, and repeat DA1 if woman is alone. (If not asked document reason as to why on DA1)
  • Review/revise management plan.

38 Weeks

  • Measure blood pressure and test urine for proteinuria.
  • Measure and plot symphysis-fundal height.
  • Discuss pattern of fetal movements.
  • Discuss options for management of prolonged labour (NICE 2008).
  • Review/revise management plan.

40 Weeks (Nulliparous Women)

  • Measure blood pressure and test urine for proteinuria.
  • Measure and plot symphysis-fundal height.
  • Discuss pattern of fetal movements.
  • Offer membrane sweep (NICE 2008). (Please refer to membrane sweep guideline).
  • Further discussion around management of prolonged pregnancy.
  • Review/revise management plan.

41 Weeks

  • Measure blood pressure and test urine for proteinuria.
  • Measure and plot symphysis-fundal height.
  • Discuss pattern of fetal movements.
  • Offer membrane sweep. (Please refer to membrane sweep guideline).
  • Discuss NICE guidelines for induction of labour.
  • Midwife to arrange appointment for induction at DGH.
  • Review/revise management plan.

From 42 Weeks

Women who decline induction of labour should be offered a consultant appointment, increased antenatal monitoring consisting of at least twice weekly CTG monitoring and ultrasound estimation of maximum amniotic pool depth.

Comment

While the above is a guideline for practice, women should be advised that the service has open access, and that they can contact a midwife at any time for advice and support.

NICE guidance (2008) states that abdominal palpation for fetal presentation prior to 36 weeks should not be offered due to its inaccuracy and discomfort it may cause. However, many women like to know the position their baby is lying in, and therefore midwives may palpate as long as the women are made aware of the limitations and discomfort it may cause.

NICE (2008) states that auscultation of the fetal heart may confirm that

the fetus is alive but is unlikely to have any predicative value, and routine

listening is not recommended. However, the majority of women like to hear their baby’s heartbeat and therefore midwives can provide this service at the request of the mother.

NICE (2008) do not recommend use of formal fetal movement counting.

The evidence does not support women counting fetal movements (i.e. 10

per day or kick charts). However women who experience a reduction in

fetal movements should be advised to contact their midwife to arrange

further assessment at a District General Hospital.

Haematology, pathology and Ultrasound Scan Requests

The midwife is responsible for ensuring that the request forms are

completed correctly and under the guidance of the referral District

General Hospital.

The midwife taking the blood must complete all blood request forms at

the time the sample is taken.

It is the responsibility of the named midwife and/or the midwife who took the test to ensure that results have been received and acted upon within ANSW specified time.

Where an abnormal results has been identified there must be no delay by any midwife in seeking medical assistance and ensuring appropriate measures are in place to deal with problems arising.