Clinical Practice Guidelines Antenatal care - Module I

Summary of recommendations

Page last updated: 02 April 2013

The recommendations in these Guidelines were developed by the Expert Advisory Committee (EAC) (see Appendices A and B) based on systematic reviews of the available evidence. Where sufficient evidence was available, this was graded according to the National Health and Medical Research Council (NHMRC) Levels of Evidence and Grades for Recommendations for Developers of Guidelines (2009) (see below) and formulated as recommendations. For areas of clinical practice included in the systematic reviews but where evidence was limited or lacking, the EAC developed consensus-based recommendations (CBRs). Some recommendations and CBRs from other national guidelines were included, where these were based on systematic review of the evidence. For areas beyond the scope of the systematic reviews, practice points (PPs) were developed by the EAC or the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care (see Appendices A and B).

The evidence-based recommendations and practice points focus on the clinical and physical aspects of care. This care is provided following principles that endorse the protection, promotion and support necessary for effective antenatal care outlined in Chapter 1 and expanded on in Part A. These include taking a holistic approach that is woman-centred, culturally appropriate and enables women to participate in informed decision-making at all stages of their care.

Definition of grades of recommendations and practice points

Grade Description
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation(s) but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
CBR Recommendation formulated in the absence of quality evidence (where a systematic review of the evidence was conducted as part of the search strategy)
PP Area is beyond the scope of the systematic literature review and advice was developed by the EAC and/or the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care
Source: Adapted from NHMRC (2009) Levels of Evidence and Grades for Recommendations for Developers of Guidelines and NHMRC (2011) Procedures and Requirements for Meeting the 2011 NHMRC Standard for Clinical Practice Guidelines.

Recommendations and practice points1

Recommendation/practice point -Antenatal visits GradeSection; page
1. Determine the schedule of antenatal visits based on the individual woman’s needs. For a woman’s first pregnancy without complications, a schedule of ten visits should be adequate. For subsequent uncomplicated pregnancies, a schedule of seven visits should be adequate. B
6.1; p31 App D; p218
I . At the first contact with a woman during pregnancy, make arrangements for the first antenatal visit, which requires a long appointment and should occur within the first 10 weeks. CBR
6.1; p31 App D; p218
ii. Early in pregnancy, provide women with information in an appropriate format about the likely number, timing and content of antenatal visits associated with different options of care and the opportunity to discuss this schedule. CBR
6.2; p34 App D; p218
a. Antenatal care should be woman-focused, with each antenatal visit structured around specific content based on the woman’s needs. Longer visits are needed early in pregnancy to allow comprehensive assessment, discussion and support. Assessments and tests should be incorporated into visits in a way that minimises inconvenience to the woman. PP
6.3; p35
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Recommendation/practice point -
Clinical assessments /
Gestational age
GradeSection; page
2 . Provide information and offer pregnant women who are unsure of their conception date an ultrasound scan between 8 weeks 0 days and 13 weeks 6 days to determine gestational age, detect multiple pregnancies and accurately time fetal anomaly screening.
Use crown–rump length (CRL) measurement to determine gestational age. If the CRL is above 84 mm, estimate the gestational age using head circumference.
B
7.1.1; p46 App D; p220
b . The timeframe for ultrasound assessment of gestational age overlaps with that for assessment of nuchal translucency thickness as part of screening for fetal chromosomal abnormalities (11 weeks to 13 weeks 6 days), which may enable some women to have both tests in a single scan. This should only occur if women have been provided with an explanation of both tests and have given their consent to them both.PP
7.1.1; p46
c . The agreed due date should not be changed without advice from a health professional with considerable experience in antenatal care.PP
7.1.1; p47
d . Ultrasound assessment of gestational age should only be performed by a person who has had specific training.PP
7.1.1; p48
e . Repeated ultrasound assessments should only be used when clinically indicated.PP
7.1.1; p48
Recommendation/practice point -
Clinical assessments /
Weight and body mass index
GradeSection; page
3 . Measure women’s weight and height at the first antenatal visit and calculate their body mass index (BMI). B
7.2.2; p53 App D; p222
F . Repeated weighing during pregnancy should be confined to circumstances that are likely to influence clinical management.PP
7.2.2; p54
4 . Give women advice about appropriate weight gain during pregnancy in relation to their BMI.B
7.2.2; p54 App D; p222
G . Taking a respectful, positive and supportive approach and providing information about healthy eating and physical activity in an appropriate format may assist discussion of weight management.PP
7.2.2; p55
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Recommendation/practice point -
Clinical assessments /
Blood pressure
GradeSection; page
5. Measure blood pressure at a woman’s first antenatal visit to identify existing high blood pressure. B
7.3.2; p60 App D; p224
Recommendation/practice point -
Clinical assessments /
Proteinuria
GradeSection; page
iii . Routinely offer testing for proteinuria at the first antenatal visit, regardless of stage of pregnancy. CBR
7.4.2; p65 App D; p226
6 . For point-of-care testing, use an automated analyser if available, as visual inspection of a urinary dipstick is the least accurate method to detect true proteinuria. B
7.4.2; p65 App D; p226
Recommendation/practice point -
Clinical assessments /
Psychosocial factors affecting mental health
GradeSection; page
iv . As early as practical in pregnancy, ask all women questions about psychosocial factors, including previous or current mental health disorders. If a woman affirms their presence, ask whether she would like help with any of these issues. CBR 7.5.2; p71 App D; p228
Recommendation/practice point -
Clinical assessments /
Depression and anxiety
GradeSection; page
7. Use the Edinburgh Postnatal Depression Scale as a component of the assessment of all women for symptoms of depression in the antenatal period. B 7.6.2; p77 App D; p228
v . Be aware that women who score 13 or more on the Edinburgh Postnatal Depression Scale (EPDS) may be experiencing anxiety, either alone or with depression. Base decisions about further assessment on the woman’s answers to questions 3, 4 and 5 of the EPDS and her response to enquiry about ‘worrying’. CBR 7.6.2; p77 8.9.2; p228
h . If a woman scores 1, 2 or 3 on EPDS question 10, assess her current safety and the safety of other children in her care and, acting according to clinical judgement, seek advice and/or refer immediately for mental health assessment. PP 7.6.2; p78
Recommendation/practice point -
Clinical assessments /
Domestic violence
GradeSection; page
8 . At the first antenatal visit, explain to all women that asking about domestic
violence is a routine part of antenatal care and enquire about each woman’s
exposure to domestic violence.
B7.7.2; p83

App D; p229

vi. Ask about domestic violence when alone with the woman, tailoring the
approach to her individual situation and your own skills and experience
(eg use open-ended questions about her perception of safety at home or
use an assessment tool).
CBR7.7.2; p83
App D; p229
vii.Be aware that training programs improve the confidence and competency of health professionals in identifying and caring for women experiencing domestic violenceCBR7.7.2; p84
App D; p229
i.Responses to assisting Aboriginal and Torres Strait Islander women
who are experiencing domestic violence need to be appropriate to the woman
and her community. Health professionals should be aware of family and
community structures and support.
PP7.7.2; p86
j.Health professionals should be aware of resources for domestic violence
services in their community that can be called for urgent assistance. This
may include local safe houses or the Strong Women Workers in their
community.
PP7.7.2; p87
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Recommendation/practice point -
Clinical assessments /
Nausea and vomiting
GradeSection; page
k. Women who experience nausea and vomiting in pregnancy can be advised
that, while it may be distressing, it usually resolves spontaneously by 16 to
20 weeks pregnancy and is not generally associated with a poor pregnancy
outcome.
PP
7.8.2; p93
i . Discontinuing iron-containing multivitamins for the period that women have symptoms of nausea and vomiting may improve symptoms.PP
7.8.2; p93
Recommendation/practice point -
Clinical assessments /
Constipation
GradeSection; page
9. Offer women who are experiencing constipation information about increasing dietary fibre intake and taking bran or wheat fibre supplementation.C
7.9.2; p97
App D; p232
10. Advise women who choose to take laxatives that preparations that stimulate
the bowel are more effective than those that add bulk but may cause more
adverse effects such as diarrhoea and abdominal pain.
C
7.9.2; p97
App D; p232
Recommendation/practice point -
Maternal health screening
/
Human immunodeficiency virus
GradeSection; page
11. Routinely offer and recommend HIV testing at the first antenatal visit as effective interventions are available to reduce the risk of mother-to-child transmission.B
8.1.2; p104
App D; p233
m. A system of clear referral paths ensures that pregnant women who are diagnosed with an HIV infection are managed and treated by the appropriate specialist teams.PP
8.1.2; p104
Recommendation/practice point -
Maternal health screening
/
Hepatitis B
GradeSection; page
12. Routinely offer and recommend hepatitis B virus testing at the first antenatal visit as effective postnatal intervention can reduce the risk of mother-to-child transmission. A
8.2.2; p110 App D; p235
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Recommendation/practice point -
Maternal health screening
/
Hepatitis C
GradeSection; page
13. Do not routinely offer pregnant women hepatitis C testing.
C
8.3.2; p115
App D; p236
n. Hepatitis C testing may be offered to women with identifiable risk factors:
  • intravenous drug use or needle sharing;
  • tattooing or body piercing;
  • incarceration;
  • receipt of blood products or invasive procedures overseas or before 1990 in Australia; or
  • country of origin has a high prevalence of hepatitis C.
PP
8.3.2; p116
o. Women who are having an invasive procedure (eg chorionic villus sampling,
amniocentesis) should be offered screening for hepatitis C before the
procedure.
PP
8.3.2; p116
Recommendation/practice point -
Maternal health screening
/
Rubella
GradeSection; page
14.Routinely offer and recommend testing for rubella immunity at the first antenatal visit to identify women at risk of contracting rubella and enable postnatal vaccination to protect future pregnancies.B 8.4.2; p120 App D; p237
15. Inform women who have been vaccinated against rubella before they were aware of the pregnancy that the baby is highly unlikely to have been affected by the vaccine. A
8.4.2; p120 App D; p237
p. Women identified as non-immune to rubella antenatally should be advised to avoid contact with people experiencing possible symptoms of rubella. PP
8.4.2; p120
Recommendation/practice point -
Maternal health screening
/
Chlamydia
GradeSection; page
16. Do not routinely offer chlamydia testing to all women as part of antenatal care. Routinely offer chlamydia testing at the first antenatal visit to pregnant women younger than 25 years. C 8.5.2; p125 App D; p238
q. Testing for chlamydia and other sexually transmitted infections regardless of age should be considered for women who live in areas where their prevalence is high. An understanding of local prevalence will inform planning for population screening when this is indicated.
PP
8.5.2; p125
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Recommendation/practice point -
Maternal health screening
/
Syphilis
GradeSection; page
17. Routinely offer and recommend syphilis testing at the first antenatal visit as treating syphilis benefits both mother and baby.
B 8.6.2; p130 App D; p239
r . Because syphilis is a rare condition in most parts of Australia and a positive result does not necessarily mean that a woman has syphilis, expert advice regarding the care of women who test positive and their partners should be sought. Assessment/testing for other sexually transmitted infections in women with positive serology is advisable. PP
8.6.2; p131
Recommendation/practice point -
Maternal health screening
/
Asymptomatic bacteriuria
GradeSection; page
18. Routinely offer and recommend testing for asymptomatic bacteriuria early in pregnancy as treatment is effective and reduces the risk of pyelonephritis. A 8.7.2; p135 App D; p240
19 . Use urine culture testing wherever possible as it is the most accurate means of detecting asymptomatic bacteriuria. A
8.7.2; p135 App D; p240
s. Where access to pathology services is limited, dipstick tests may be used to exclude infection, with positive results confirmed by urine culture. Appropriate storage of dipsticks is essential to the accuracy of these tests. PP
8.7.2; p136
Recommendation/practice point -
Maternal health screening
/
Asymptomatic bacterial vaginosis
GradeSection; page
20. Do not routinely offer pregnant women testing for bacterial vaginosis. B 8.8.2; p140 App D; p242
t. Early treatment (before 20 weeks pregnancy) of proven bacterial vaginosis may be beneficial for women with a previous preterm birth. PP
8.8.2; p140
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Recommendation/practice point -
Maternal health screening
/
Vitamin D deficiency
GradeSection; page
viii . Offer vitamin D screening to women with limited exposure to sunlight (eg because they are predominantly indoors or usually protected from the sun when outdoors), or who have dark skin or a pre-pregnancy BMI of >30, as they may be at increased risk of vitamin D deficiency and benefit from supplementation for their long-term health. Base decisions about whether to offer screening on these factors, season and climate. CBR 8.9.2; p145 App D; p243
Recommendation/practice point -
Screening for fetal chromosomal abnormalities
/
Discussing screening tests
GradeSection; page
ix . At the first antenatal visit, give women information about the purpose and implications of testing for chromosomal abnormalities to enable them to make informed choices about whether or not to have the tests. CBR 9.2; p153 App D; p244
u. Information about testing for chromosomal abnormalities should be provided in a way that is appropriate and accessible to the individual woman, with particular regard given to language and literacy.
PP 9.2; p153
Recommendation/practice point -
Screening for fetal chromosomal abnormalities
/
Screening tests in the first trimester
GradeSection; page
21. If a woman chooses to have the combined test (nuchal translucency thickness, free beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A), make arrangements so that blood for biochemical analysis is collected between 9 weeks to 13 weeks 6 days and ultrasound assessment takes place between 11 weeks 0 days and 13 weeks 6 days. B 9.3.1; p155 App D; p244
v . For women with a risk of 1 in 300 or greater, referral to a genetic counsellor should be considered. PP 9.3.2; p155
22. If a woman chooses to have a diagnostic test for chromosomal abnormalities, base the choice of test on the gestation of pregnancy and the woman’s preferences. Chorionic villus sampling is safer before 14 weeks pregnancy. Amniocentesis is safe after 15 weeks. B 9.3.2; p156 App D; p244
x. Offer rapid access to appropriate counselling and ongoing support by trained health professionals to women who receive a diagnosis of fetal chromosomal abnormality. CBR 9.3.2; p156 App D; p244
w. Women with an high-risk first trimester screening test result but negative diagnostic test should be referred for further specialist assessment because of an increased risk of other fetal abnormalities. PP 9.3.2; p156
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Recommendation/practice point -
Screening for fetal chromosomal abnormalities / Other considerations in screening for fetal chromosomal abnormalities
GradeSection; page
x . There is inadequate access to screening for chromosomal abnormalities in many rural and remote areas. Every effort should be made to support women in these areas to access screening. PP 9.4; p157
Recommendation/practice point -
Lifestyle considerations /
Tobacco smoking


GradeSection; page
23. At the first antenatal visit:
assess the woman’s smoking status and exposure to passive smoking;
give the woman and her partner information about the risks to the unborn baby associated with maternal and passive smoking; and
if the woman smokes, emphasise the benefits of quitting as early as possible in the pregnancy and discuss any concerns she or her family may have about stopping smoking.
A 10.1.2; p166 App D; p247
24. Offer women who smoke referral for smoking cessation interventions such as cognitive behavioural therapy. B 10.1.3; p167 App D; p247
y. At each antenatal visit, offer women who smoke personalised advice on how to stop smoking and provide information about available services to support quitting, including details on when, where and how to access them.
PP 10.1.3; p167
25. If, after other options have been explored, a woman expresses a clear wish to use nicotine replacement therapy, discuss the risks and benefits with her. B 10.1.3; p167 App D; p247
z . If nicotine replacement therapy is used during pregnancy, intermittent–use formulations (gum, lozenge, inhaler and tablet) are preferred to continuous-use formulations (nicotine patches). PP 10.1.3; p167
aa . Smoking status should be monitored and smoking cessation advice, encouragement and support offered throughout pregnancy. PP 10.1.3; p168
bb . Health care professionals involved in the care of Aboriginal and Torres Strait Islander women should be aware of the high prevalence of smoking in some communities, and take account of this social norm when discussing smoking and supporting women to quit. PP 10.1.4; p169
cc. Culturally appropriate smoking cessation services should be offered. PP 10.1.4; p169
dd . In discussing smoking and supporting Aboriginal and Torres Strait Islander women to quit smoking, health professionals should draw on the expertise of anti-tobacco workers where available. PP 10.1.4; p169
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Recommendation/practice point -
Lifestyle considerations /
Alcohol


GradeSection; page
xi. Advise women who are pregnant or planning a pregnancy that not drinking is the safest option as maternal alcohol consumption may adversely affect the developing fetus.
CBR 10.2.2; p178

Recommendation/practice point -
Lifestyle considerations /
Medicines


GradeSection; page
xii. Advise women that use of prescription and over-the-counter medicines should be limited to circumstances where the benefit outweighs the risk as few medicines have been established as safe to use in pregnancy. CBR 10.3.1; p183 App D; p249
xiii.Therapeutic Goods Administration Category A medicines have been established to be safe in pregnancy. CBR 10.3.1; p183 App D; p249
ee. Health professionals should seek advice from a tertiary referral centre for women who have been exposed to Category D or X medicines during pregnancy. PP 10.3.1; p183
ff. Few herbal preparations have been established as being safe and effective during pregnancy. Herbal medicines should be avoided in the first trimester. PP 10.3.3; p183
Recommendation/practice point -
Lifestyle considerations /
Nutritional supplements


GradeSection; page
26.Inform women that dietary supplementation with folic acid, from 12 weeks before conception and throughout the first 12 weeks of pregnancy, reduces the risk of having a baby with a neural tube defect and recommend a dose of 500 micrograms per day. A 10.4.1; p187 App D; p250
gg. Specific attention needs to be given to promoting folic acid supplementation to Aboriginal and Torres Strait Islander women of childbearing age and providing information to individual women at the first antenatal visit. PP 10.4.1; p187
27 . Advise women that taking vitamins A, C or E supplements is not of benefit in pregnancy and may cause harm. B 10.4.2; p188 App D; p251
xiv . Advise women who are pregnant to take an iodine supplement of 150 micrograms each day. Women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking a supplement. CBR 10.4.3; p188
28.Do not routinely offer iron supplementation to women during pregnancy. B 10.4.4; p188 App D; p251
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Recommendation/practice point -
Lifestyle considerations /
Oral health


GradeSection; page
29. At the first antenatal visit, advise women to have oral health checks and treatment, if required, as good oral health protects a woman’s health and treatment can be safely provided during pregnancy.
B 10.5.2; p193 App D; p252

1 Recommendations are numbered using Arabic numerals (eg 1, 2, 3), consensus-based recommendations using Roman numerals (eg i, ii, iii) and practice points using letters (eg a, b, c).