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Pregnancy Care Guidelines

Summary of recommendations and practice points

The recommendations in these Guidelines were developed by the Expert Advisory Committees (EACs) (see Appendix A and Appendix B) based on systematic reviews of the available evidence. Sets of systematic reviews were conducted in 2010–2011, 2012–2013 and 2016–2017. 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) for the 2010–2011 and 2012–2013 reviews and using GRADE methods for the 2016–2017 reviews. Recommendations were approved by the NHMRC in December 2011, June 2014 and October 2017, respectively. Topics prioritised for future review are included in Appendix C and marked as under review in this summary of recommendations.

For all reviews, where evidence was limited or lacking, consensus-based recommendations (CBRs) were developed. Some recommendations and CBRs from other national guidelines have also been 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, the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care and/or the Working Group for Migrant and Refugee Women’s Antenatal Care (see Appendices A and B).

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

Definition of grades of recommendations (2010–11 and 2012–13 reviews)

Grade A
Body of evidence can be trusted to guide practice
Grade B
Body of evidence can be trusted to guide practice in most situations
Grade C
Body of evidence provides some support for recommendation(s) but care should be taken in its application
Grade D
Body of evidence is weak and recommendation must be applied with caution
Consensus-based recommendation
Recommendation formulated in the absence of quality evidence (where a systematic review of the evidence was conducted as part of the search strategy)
Practice point
Area is beyond the scope of the systematic literature review and advice was developed by the EAC

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. 

Definition of grades of recommendations (2016–17 reviews)

Evidence-based recommendation (EBR)
Body of evidence can be trusted to guide practice
Qualified evidence-based recommendation (QEBR)
Body of evidence can be trusted to guide practice in most situations
Consensus-based recommendation (CBR)
Recommendation formulated in the absence of quality evidence (where a systematic review of the evidence was conducted as part of the search strategy)
Practice point (PP)
Area is beyond the scope of the systematic literature review and advice was developed by the EAC

List of recommendations and practice points

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).

Part A: Optimising pregnancy care

3 Pregnancy care for Aboriginal and Torres Strait Islander women

  • Practice point
  • A

Adopt a respectful, positive and supportive approach in providing antenatal care to Aboriginal and Torres Strait Islander women, working in partnership with women, Aboriginal and Torres Strait Islander health professionals and communities. This should be informed by cultural safety training for health professionals.

Approved by NHMRC in October 2017; expires October 2022

4 Pregnancy care for migrant and refugee women

  • Practice point
  • B

The care needs of migrant and refugee women can be complex. The first point of contact (eg first antenatal visit) is important and care should be undertaken with an accredited health interpreter. Wherever possible, antenatal care should involve a multicultural health worker.

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • C

Health professionals should take the initiative in organising for an accredited health interpreter wherever necessary, and reassure the woman of the benefits if she is reluctant.

Approved by NHMRC in June 2014; expires June 2019

5 Pregnancy care for women with severe mental illness

  • Practice point
  • D

For women with borderline personality disorder who have often experienced complex trauma, trauma-informed care and specific support for health professionals in dealing with challenging behaviours is a priority.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • E

For women with schizophrenia, bipolar disorder or borderline personality disorder, a multidisciplinary team approach to care in the antenatal period is essential, with clear communication, advance care planning, a written plan, and continuity of care across different clinical settings.

Approved by NHMRC in October 2017; expires 2022

  • Practice point
  • F

Where possible, health professionals providing care in the antenatal period should access training to improve their understanding of care for women with schizophrenia, bipolar disorder and borderline personality disorder.

Approved by NHMRC in October 2017; expires October 2022

Part B: Core practices in pregnancy care

8 Antenatal visits

  • Grade B
  • 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. 

Approved by NHMRC in December 2011; expires December 2016

  • Consensus-based
  • 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.

Approved by NHMRC in December 2011; expires December 2016

  • Consensus-based
  • 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.

Approved by NHMRC in December 2011; expires December 2016

9 Preparing for pregnancy, childbirth and parenthood

  • Grade B
  • 2

Advise parents that antenatal education programs are effective in providing information about pregnancy, childbirth and parenting but do not influence mode of birth. 

Approved by NHMRC in June 2014; expires June 2019

  • Grade B
  • 3

Include psychological preparation for parenthood as part of antenatal care as this has a positive effect on women’s mental health postnatally. 

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • G

Assisting parents to find an antenatal education program that is suitable to their learning style, language and literacy level may improve uptake of information. 

Approved by NHMRC in June 2014; expires June 2019

10 Preparing for breastfeeding

  • Grade C
  • 4

Routinely offer education about breastfeeding as part of antenatal care.

Approved by NHMRC in June 2014; expires June 2019

Part C: Lifestyle considerations

11 Nutrition and physical activity

  • Practice point
  • H

Eating the recommended number of daily serves of the five food groups and drinking plenty of water is important during pregnancy and breastfeeding.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade C
  • 5

Reassure women that small to moderate amounts of caffeine are unlikely to harm the pregnancy. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • I

For women who are underweight, additional serves of the five food groups may contribute to healthy weight gain.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • J

For women who are overweight or obese, limiting additional serves and avoiding energy-dense foods may limit excessive weight gain. Weight loss diets are not recommended during pregnancy. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade A
  • 6

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.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Practice point
  • K

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.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Grade B
  • 7

Advise women that taking vitamin A, C or E supplements is not of benefit in pregnancy and may cause harm.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Consensus-based
  • III

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.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Grade B
  • 8

Do not routinely offer iron supplementation to women during pregnancy.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Grade B
  • 9

Advise women with low dietary iron intake that intermittent supplementation is as effective as daily supplementation in preventing iron-deficiency anaemia, with fewer side effects.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • L

Women at risk of iron deficiency due to limited access to dietary iron may benefit from practical advice on increasing intake of iron-rich foods.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade B
  • 10

Advise women that low- to moderate-intensity physical activity during pregnancy is associated with a range of health benefits and is not associated with adverse outcomes.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

12 Tobacco smoking

  • Grade A
  • 11

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
  • 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.

Approved by NHMRC in December 2011; expires December 2016

  • Grade B
  • 12

Offer women who smoke referral for smoking cessation interventions such as cognitive behavioural therapy.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • M

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.

Approved by NHMRC in December 2011; expires December 2016

  • Grade B
  • 13

If, after options have been explored, a woman expresses a clear wish to use nicotine replacement therapy, discuss the risks and benefits with her.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • N

If nicotine replacement therapy is used during pregnancy, intermittent–use formulations (gum, lozenge, inhaler and tablet) are preferred to continuous-use formulations (nicotine patches).

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • O

Smoking status should be monitored and smoking cessation advice, encouragement and support offered throughout pregnancy.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • P

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.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • Q

Culturally appropriate smoking cessation services should be offered.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • R

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.

Approved by NHMRC in December 2011; expires December 2016

13 Alcohol

  • Consensus-based
  • IV

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.

Approved by NHMRC in December 2011; expires December 2016

14 Medicines

  • Consensus-based
  • V

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.

Approved by NHMRC in December 2011; expires December 2016

  • Consensus-based
  • VI

Therapeutic Goods Administration Category A medicines have been established to be safe in pregnancy.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • S

Health professionals should seek advice from a tertiary referral centre for women who have been exposed to Category D or X medicines during pregnancy.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • T

Few herbal preparations have been established as being safe and effective during pregnancy. Herbal medicines should be avoided in the first trimester.

Approved by NHMRC in December 2011; expires December 2016

15 Substance use

  • Consensus-based
  • VII

Early in pregnancy, assess a woman’s use of illicit substances and misuse of pharmaceuticals and provide advice about the associated harms.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • U

Asking about substance use at subsequent visits is important as some women are more likely to report sensitive information only after a trusting relationship has been established.

Approved by NHMRC in October 2017; expires October 2022

16 Oral health

  • Grade B
  • 14

At the first antenatal visit, advise women to have oral health checks and treatment, if required, as good oral health is important to a woman’s health and treatment can be safely provided during pregnancy.

Approved by NHMRC in December 2011; expires December 2016

17 Sexual activity

  • Grade B
  • 15

Advise pregnant women without complications that safe sexual activity in pregnancy is not known to be associated with any adverse outcomes. 

Approved by NHMRC in June 2014; expires June 2019

18 Travel

  • Grade B
  • 16

Inform pregnant women about the correct use of seat belts; that is, three-point seat belts ‘above and below the bump, not over it’.

Approved by NHMRC in June 2014; expires June 2019

  • Grade C
  • 17

Inform pregnant women that long-distance air travel is associated with an increased risk of venous thrombosis and pulmonary embolism, although it is unclear whether there is additional risk during pregnancy.

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • V

Pregnant women should be advised to discuss considerations such as air travel, vaccinations and travel insurance with their midwife or doctor if they are planning to travel overseas. 

Approved by NHMRC in June 2014; expires June 2019

  • Grade B
  • 18

If pregnant women cannot defer travel to malaria-endemic areas, advise them to use insecticide-treated bed nets. 

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • W

Beyond the first trimester, mefloquine is approved for use to prevent malaria. Neither malarone nor doxycycline are recommended for prophylaxis any time during pregnancy. Chloroquine (or hydroxychloroquine) plus proguanil is safe but less effective so seldom used. For areas where only vivax is endemic, chloroquine or hydroxychloroquine alone is appropriate.

Approved by NHMRC in June 2014; expires June 2019

Part D: Clinical Assessments

19 Weight and body mass index

  • Consensus-based
  • VIII

Measure women’s weight and height at the first antenatal visit and calculate their body mass index (BMI) to inform gestational weight gain.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Consensus-based
  • IX

Give women advice about appropriate weight gain during pregnancy in relation to their pre-pregnancy BMI (if recorded) or their BMI at the first antenatal visit.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Practice point
  • X

Adopting 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. This should be informed by appropriate education for health professionals.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Consensus-based
  • X

At every antenatal visit, offer women the opportunity to be weighed and encourage self-monitoring of weight gain.

Approved by NHMRC in October 2017; expires October 2022 UNDER REVIEW

  • Consensus-based
  • XI

At every antenatal visit, discuss weight change, diet and level of physical activity with all women.

Approved by NHMRC in October 2017; expires October 2022 UNDER REVIEW

20 Gestational age

  • Grade B
  • 19

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 testing.

Approved by NHMRC in December 2011; expires December 2016

  • Grade B
  • 20

Use crown–rump length (CRL) measurement to determine gestational age. If the CRL is above 84 mm, estimate the gestational age using head circumference.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • Y

The timeframe for ultrasound assessment of gestational age overlaps with that for assessment of nuchal translucency thickness as part of testing for fetal chromosomal anomalies (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 the purpose and implications of the tests and have given their informed consent to both tests.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • Z

The agreed due date should not be changed without advice from another health professional with considerable experience in antenatal care.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • AA

Ultrasound assessment of gestational age should only be performed by a person who has had specific training.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • BB

Repeated ultrasound assessments should only be used when clinically indicated.

Approved by NHMRC in December 2011; expires December 2016

21 Fetal development and anatomy

  • Grade B
  • 21

Offer pregnant women ultrasound screening to assess fetal development and anatomy between 18 and 20 weeks gestation.

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • CC

Timing of the ultrasound will be guided by the individual situation (eg for women who are obese, visualisation may improve with gestational age).

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • DD

Repeated ultrasound assessment may be appropriate for specific indications but should not be used for routine monitoring. 

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • EE

Ultrasound assessment should only be performed by healthcare professionals with appropriate training and qualifications, within the appropriate scope (eg diagnostic or point of care). 

Approved by NHMRC in June 2014; expires June 2019

22 Fetal growth restriction and well-being

  • Practice point
  • FF

Early in pregnancy, assess women for risk factors for having a small-for-gestational-age fetus/newborn.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XII

When women are identified as being at risk of having a small-for-gestational-age fetus/newborn, provide advice about modifiable risk factors. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XIII

Refer women with a major risk factor or multiple other factors associated with having a small-for-gestational-age fetus/newborn for ultrasound assessment of fetal size and wellbeing at 28–30 and 34–36 weeks gestation.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XIV

Do not assess fetal growth based solely on abdominal palpation.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XV

At each antenatal visit from 24 weeks, measure fundal height in centimetres.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • GG

Refer women after 24 weeks gestation with a fundal height ≥3cm less than expected, a single fundal height which plots below the 10th centile or serial measurements that demonstrate slow or static growth by crossing centiles for ultrasound measurement of fetal size.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • HH

Refer women in whom measurement of fundal height is inaccurate (for example: BMI >35, large fibroids, polyhydramnios) for serial assessment of fetal size using ultrasound.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XVI

Early in pregnancy provide women with verbal and written information about normal fetal movements. This information should include a description of the changing patterns of movement as the fetus develops, normal wake/sleep cycles and factors that may modify the mother’s perception of fetal movements.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XVII

Advise women with a concern about decreased fetal movements to contact their health professional immediately.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • II

Emphasise the importance of maternal awareness of fetal movements at every antenatal visit.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XVIII

Do not advise the use of kick charts as part of routine antenatal care.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • JJ

Maternal concern about decreased fetal movements overrides any definition of decreased fetal movements based on numbers of fetal movements.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XIX

If auscultation of the fetal heart rate is performed, a Doppler may be used from 12 weeks and either Doppler or a Pinard stethoscope from 28 weeks.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XX

Do not routinely use electronic fetal heart rate monitoring (cardiotocography) for fetal assessment in women with an uncomplicated pregnancy.

Approved by NHMRC in October 2017; expires October 2022

23 Risk of preterm birth

  • Consensus-based
  • XXI

When women are identified as being at risk of giving birth preterm based on the presence of risk factors, provide advice about modifiable risk factors.

Approved by NHMRC in October 2017; expires October 2022

24 Blood pressure

  • Grade B
  • 22

Measure blood pressure at a woman’s first antenatal visit to identify existing high blood pressure.

Approved by NHMRC in December 2011; expires December 2016

25 Proteinuria

  • Consensus-based
  • XXII

Routinely offer testing for proteinuria at the first antenatal visit, regardless of stage of pregnancy.

Approved by NHMRC in December 2011; expires December 2016

  • Grade B
  • 23

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.

Approved by NHMRC in December 2011; expires December 2016

26 Risk of pre-eclampsia

  • Evidence-based
  • 24

Early in pregnancy, assess all women for clinical risk factors for pre-eclampsia. 

Approved by NHMRC in October 2017; expires October 2022 UNDER REVIEW

  • Grade A
  • 25

Advise women at high risk of developing pre-eclampsia that calcium supplementation is beneficial if dietary intake is low.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • KK

If a woman has a low dietary calcium intake, advise her to increase her intake of calcium-rich foods.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade B
  • 26

Advise women at moderate–high risk of pre-eclampsia that low-dose aspirin from early pregnancy may be of benefit in its prevention.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade B
  • 27

Advise women that vitamins C and E are not of benefit in preventing pre-eclampsia.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Consensus-based
  • XXIII

Routinely measure blood pressure to identify new onset hypertension.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Consensus-based
  • XXIV

Recommend testing for proteinuria at each antenatal visit if a woman has risk factors for or clinical indications of pre-eclampsia, in particular, raised blood pressure.

Approved by NHMRC in October 2017; expires October 2022 UNDER REVIEW

  • Practice point
  • LL

Give women information about the urgency of seeking advice from a health professional if they experience: headache, visual disturbance (such as blurring or flashing before the eyes), epigastric pain (just below the ribs), vomiting and/or rapid swelling of the face, hands or feet. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

Part E: Social and emotional screening

27 Screening for depressive and anxiety disorders

  • Evidence-based
  • 28

Use the Edinburgh Postnatal Depression Scale (EPDS) to screen women for a possible depressive disorder.

Approved by NHMRC in October 2017; expires October 2022

  • Evidence-based
  • 29

Arrange further assessment of woman with an EPDS score of 13 or more. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXV

Conduct screening as early as practical in pregnancy and repeat at least once later in pregnancy.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXVI

For a woman with an EPDS score between 10 and 12, monitor and repeat the EPDS in 4–6 weeks as her score may increase subsequently. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXVII

Repeat the EPDS at any time in pregnancy if clinically indicated. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXVIII

For a woman with a positive score on Question 10 on the EPDS, undertake or arrange immediate further assessment and, if there is any disclosure of suicidal ideation, take urgent action in accordance with local protocol/policy. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXIX

When screening Aboriginal and Torres Strait Islander women, consider language and cultural appropriateness of the tool.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXX

Use appropriately translated versions of the EPDS with culturally relevant cut-off scores.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXXI

Be aware that anxiety disorder is very common in the perinatal period and should be considered in the broader clinical assessment.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXXII

As part of the clinical assessment, use anxiety items from other screening tools (eg EPDS items 3, 4 and 5; Depression Anxiety Stress Scale anxiety items; and Kessler Psychological Distress Scale items 2, 3, 5 and 6) and relevant items in structured psychosocial assessment tools (eg the Antenatal Risk Questionnaire [ANRQ]). 

Approved by NHMRC in October 2017; expires October 2022

28 Assessing psychosocial factors that affect mental health

  • Practice point
  • MM

Assess psychosocial risk factors as early as practical in pregnancy.

Approved by NHMRC in October 2017; expires October 2022

  • Evidence-based
  • 30

If using a tool to assess psychosocial risk, administer the ANRQ. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXXIII

Undertake psychosocial assessment in conjunction with a tool that screens for current symptoms of depression/anxiety (eg the EPDS).

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • NN

Ensure that health professionals receive training in the importance of psychosocial assessment and the use of a psychosocial assessment tool.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • OO

Ensure that there are clear guidelines around the use and interpretation of the psychosocial tool/ interview in terms of threshold for referral for psychosocial care and/or ongoing monitoring.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • PP

Discuss with the woman the possible impact of psychosocial risk factors (she has endorsed) on her mental health and provide information about available assistance.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXXIV

Consider language and cultural appropriateness of any tool used to assess psychosocial risk. 

Approved by NHMRC in October 2017; expires October 2022

29 Family violence

  • Evidence-based
  • 31

Explain to all women that asking about family violence is a routine part of antenatal care and enquire about each woman’s exposure to family violence.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXXV

Ask about family violence only when alone with the woman, using specific questions or the tool used in your state/territory.

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XXXVI

Undertake and encourage regular and repeat training of health professionals, as training programs improve confidence and competence in identifying and caring for women experiencing family violence.

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • QQ

Be aware of family and community structures and support, and of community family violence and sexual assault services that can be called for urgent and ongoing support. 

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • RR

Responses to assisting Aboriginal and Torres Strait Islander women who are experiencing family violence need to be appropriate to the woman and her community.

Approved by NHMRC in October 2017; expires October 2022

Part F: Routine maternal health tests

30 Anaemia

  • Consensus-based
  • XXXVII

Routinely offer testing for haemoglobin concentration to pregnant women early in pregnancy (at the first visit) and at 28 weeks gestation.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • SS

In areas where prevalence of iron-deficiency anaemia is high consider testing ferritin at the first antenatal visit.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • TT

Further investigation is required for women with a low haemoglobin concentration for their gestational stage. Repeat testing at 36 weeks may also be required for women who have symptoms or risk factors for anaemia or who live in or have come from an area of high prevalence. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade B
  • 32

Advise iron supplementation for women identified as having iron-deficiency anaemia. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • UU

Oral iron remains first-line treatment for iron-deficiency anaemia identified in the antenatal period. Intravenous iron should be offered to women who do not respond to oral iron or are unable to comply with therapy. In some remote settings, intramuscular iron may be administered by a health professional who does not have intravenous endorsement or where intravenous iron cannot be accessed.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade B
  • 33

Advise women with iron-deficiency anaemia that low-dose iron supplementation is as effective as high dose, with fewer side effects.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

31 Haemoglobin disorders

  • Consensus-based
  • XXXVIII

As early as possible in pregnancy, routinely provide information about haemoglobin disorders and offer testing (full blood count). 

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • VV

Consider offering ferritin testing and haemoglobin electrophoresis as part of initial testing to women from high-risk population groups. 

Approved by NHMRC in June 2014; expires June 2019

32 Hyperglycaemia

  • Evidence-based
  • 34

In the first trimester, assess a woman’s risk of hyperglycaemia including: her age, body mass index, previous gestational diabetes or high birth weight baby, family history of diabetes, presence of polycystic ovarian syndrome and whether she is from an ethnic group with high prevalence of diabetes, such as Aboriginal and Torres Strait Islander peoples

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Qualified evidence-based
  • 35

Advise women that physical activity and healthy eating during pregnancy help to reduce excessive weight gain but do not appear to directly reduce the risk of diabetes in pregnancy.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Consensus-based
  • XXXIX

When a woman has risk factors for hyperglycaemia in the first trimester, suitable tests are glycated haemoglobin (HbA1c) or fasting blood glucose. 

Approved by NHMRC in October 2017; expires October 2022 UNDER REVIEW

  • Consensus-based
  • XL

Between 24 and 28 weeks gestation, advise testing for hyperglycaemia to all women who have not previously been tested in the current pregnancy. Advise repeat testing to women who were tested early in pregnancy due to risk factors and who had a normal result on an initial test.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Consensus-based
  • XLI

Use the World Health Organization/International Association of Diabetes and Pregnancy Study Groups tests and criteria to diagnose diabetes and gestational diabetes in pregnancy.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

33 Human immunodeficiency virus

  • Grade B
  • 36

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.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • WW

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.

Approved by NHMRC in December 2011; expires December 2016

34 Hepatitis B

  • Grade A
  • 37

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. 

Approved by NHMRC in December 2011; expires December 2016

35 Hepatitis C

  • Consensus-based
  • XLII

At the first antenatal visit, recommend testing for hepatitis C. 

Approved by NHMRC in October 2017; expires October 2022

  • Practice point
  • XX

For women who have not previously been tested and who are having a planned invasive procedure (eg chorionic villus sampling), recommend testing for hepatitis C before the procedure.

Approved by NHMRC in October 2017; expires October 2022

36 Syphilis

  • Grade B
  • 38

Routinely offer and recommend syphilis testing at the first antenatal visit as treating syphilis benefits both mother and baby.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

  • Practice point
  • YY

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.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

37 Rubella

  • Grade B
  • 39

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.

Approved by NHMRC in December 2011; expires December 2016

  • Grade A
  • 40

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.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • ZZ

Women identified as non-immune to rubella antenatally should be advised to avoid contact with people experiencing possible symptoms of rubella.

Approved by NHMRC in December 2011; expires December 2016

38 Asymptomatic bacteriuria

  • Grade A
  • 41

Routinely offer and recommend testing for asymptomatic bacteriuria early in pregnancy as treatment is effective and reduces the risk of pyelonephritis.

Approved by NHMRC in December 2011; expires December 2016

  • Grade A
  • 42

Use urine culture testing wherever possible, as it is the most accurate means of detecting asymptomatic bacteriuria.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • AAA

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.

Approved by NHMRC in December 2011; expires December 2016

39 Group B streptococcus

  • Grade C
  • 43

Offer either routine antenatal testing for Group B streptococcus colonisation or a risk factor-based approach to prevention, depending on organisational policy.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade B
  • 44

If offering antenatal testing for Group B streptococcus, arrange for testing to take place at 35–37 weeks gestation.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Grade C
  • 45

Encourage women to self-collect vaginal-rectal specimens for culture testing for Group B streptococcus and offer information about how to do this. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

Part G: Targeted maternal health tests

40 Chlamydia

  • Grade C
  • 46

Do not routinely offer chlamydia testing to all women as part of antenatal care. 

Approved by NHMRC in December 2011; expire December 2016 UNDER REVIEW

  • Grade C
  • 47

Routinely offer chlamydia testing at the first antenatal visit to pregnant women younger than 25 years. 

Approved by NHMRC in December 2011; expire December 2016 UNDER REVIEW

  • Practice point
  • BBB

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 testing when this is indicated.

Approved by NHMRC in December 2011; expire December 2016 UNDER REVIEW

41 Gonorrhoea

  • Consensus-based
  • XLIII

Do not routinely offer gonorrhoea testing to all women as part of antenatal care. Offer gonorrhoea testing to pregnant women who have known risk factors or who live in or come from areas where prevalence is high.

Approved by NHMRC in June 2014; expires June 2019

42 Trichomoniasis

  • Grade B
  • 48

Offer testing to women who have symptoms of trichomoniasis, but not to asymptomatic women. 

Approved by NHMRC in June 2014; expires June 2019

43 Toxoplasmosis

  • Grade C
  • 49

Do not routinely offer testing for toxoplasmosis to pregnant women. 

Approved by NHMRC in June 2014; expires June 2019

  • Grade C
  • 50

Advise pregnant women about measures to avoid toxoplasmosis infection such as:

  • washing hands before handling food
  • thoroughly washing all fruit and vegetables, including ready-prepared salads, before eating
  • thoroughly cooking raw meat and ready-prepared chilled meals
  • wearing gloves and thoroughly washing hands after handling soil and gardening
  • avoiding cat faeces in cat litter or in soil. 

Approved by NHMRC in June 2014; expires June 2019

44 Cytomegalovirus

  • Consensus-based
  • XLIV

Only offer testing for cytomegalovirus to pregnant women if they come into frequent contact with large numbers of very young children (eg child care workers). 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Consensus-based
  • XLV

Advise pregnant women about hygiene measures to prevent cytomegalovirus infection such as frequent hand washing, particularly after exposure to a child’s saliva or urine. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

45 Asymptomatic bacterial vaginosis

  • Grade B
  • 51

Do not routinely offer pregnant women testing for bacterial vaginosis.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • CCC

Early treatment (before 20 weeks pregnancy) of proven bacterial vaginosis may be beneficial for women with a previous preterm birth.

Approved by NHMRC in December 2011; expires December 2016

46 Thyroid dysfunction

  • Evidence-based
  • 52

Do not routinely test pregnant women for thyroid dysfunction. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XLVI

Recommend thyroid testing to pregnant women who are at increased risk of thyroid dysfunction. 

Approved by NHMRC in October 2017; expires October 2022

47 Vitamin D status

  • Evidence-based
  • 53

Do not routinely recommend testing for vitamin D status to pregnant women in the absence of a specific indication. 

Approved by NHMRC in October 2017; expires October 2022

  • Consensus-based
  • XLVII

If testing is performed, only recommend vitamin D supplementation for women with vitamin D levels lower than 50 nmol/L

Approved by NHMRC in October 2017; expires October 2022

48 Human papilloma virus

  • Consensus-based
  • XLVIII

Offer women cervical screening as specified by the National Cervical Screening Program. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

Part H: Fetal chromosomal anomalies

50 Tests for probability of chromosomal anomalies

  • Consensus-based
  • XLIX

In the first trimester, give all women/couples information about the purpose and implications of testing for probability of chromosomal anomalies to enable them to make informed choices. 

Approved by NHMRC in December 2011; expires December 2016

  • Consensus-based
  • L

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 and 13 weeks 6 days gestation and ultrasound assessment takes place between 11 weeks and 13 weeks 6 days gestation.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • DDD

Provide information about chromosomal anomalies and the tests used to identify their probability in a way that is appropriate and accessible to the individual woman. 

Approved by NHMRC in December 2011; expires December 2016

51 Diagnostic testing

  • Grade B
  • 54

If a woman chooses to have a diagnostic test for chromosomal anomaly, base the choice of test on gestational age (chorionic villus sampling before 14 weeks pregnancy and amniocentesis after 15 weeks) and the woman’s/couple’s preferences. 

Approved by NHMRC in December 2011; expires December 2016

  • Consensus-based
  • LI

Offer rapid access to appropriate counselling and ongoing support by trained health professionals to women who receive a diagnosis of fetal chromosomal anomaly. 

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • EEE

Refer women with a high-probability screening test result but negative diagnostic test for further specialist assessment because of the increased likelihood of other fetal anomalies. 

Approved by NHMRC in December 2011; expires December 2016

52 Other considerations in testing for fetal chromosomal anomalies

  • Practice point
  • FFF

Support all women to access testing for chromosomal anomalies in a timely manner.

Approved by NHMRC in December 2011; expires December 2016

Part I: Common conditions during pregnancy

54 Nausea and vomiting

  • Practice point
  • GGG

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.

Approved by NHMRC in December 2011; expires December 2016

  • Practice point
  • HHH

Discontinuing iron-containing multivitamins for the period that women have symptoms of nausea and vomiting may improve symptoms.

Approved by NHMRC in December 2011; expires December 2016

55 Constipation

  • Grade C
  • 55

Offer women who are experiencing constipation information about increasing dietary fibre intake and taking bran or wheat fibre supplementation.

Approved by NHMRC in December 2011; expires December 2016

  • Grade C
  • 56

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.

Approved by NHMRC in December 2011; expires December 2016

56 Reflux (heartburn)

  • Consensus-based
  • LII

Offer women experiencing mild symptoms of heartburn advice on lifestyle modifications and avoiding foods that cause symptoms on repeated occasions.

Approved by NHMRC in June 2014; expires June 2019

  • Grade C
  • 57

Give women who have persistent reflux information about treatments.

Approved by NHMRC in June 2014; expires June 2019

57 Haemorrhoids

  • Consensus-based
  • LIII

Offer women who have haemorrhoids information about increasing dietary fibre and fluid intake. If clinical symptoms remain, advise women that they can consider using standard haemorrhoid creams.

Approved by NHMRC in June 2014; expires June 2019

58 Varicose veins

  • Consensus-based
  • LIV

Advise women that varicose veins are common during pregnancy, vary in severity, will not generally cause harm and usually improve after the birth. Correctly fitted compression stockings may be helpful.

Approved by NHMRC in June 2014; expires June 2019

59 Pelvic girdle pain

  • Grade C
  • 58

Advise women experiencing pelvic girdle pain that pregnancy-specific exercises, physiotherapy, acupuncture or using a support garment may provide some pain relief. 

Approved by NHMRC in June 2014; expires June 2019

60 Carpal tunnel syndrome

  • Consensus-based
  • LV

Advise women who are experiencing symptoms of carpal tunnel syndrome that the evidence to support either splinting or steroid injections is limited and symptoms may resolve after the birth. 

Approved by NHMRC in June 2014; expires June 2019

Part J: Clinical assessments in late pregnancy

61 Fetal presentation

  • Grade C
  • 59

Assess fetal presentation by abdominal palpation at 36 weeks or later, when presentation is likely to influence the plans for the birth.

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • III

Suspected non-cephalic presentation after 36 weeks should be confirmed by an ultrasound assessment.

Approved by NHMRC in June 2014; expires June 2019

  • Grade B
  • 60

Offer external cephalic version to women with uncomplicated singleton breech pregnancy after 37 weeks of gestation.

Approved by NHMRC in June 2014; expires June 2019

  • Consensus-based
  • LVI

Relative contraindications for external cephalic version include a previous caesarean section, uterine anomaly, vaginal bleeding, ruptured membranes or labour, oligohydramnios, placenta praevia and fetal anomalies or compromise. 

Approved by NHMRC in June 2014; expires June 2019

  • Practice point
  • JJJ

External cephalic version should be performed by a health professional with appropriate expertise.

Approved by NHMRC in June 2014; expires June 2019

62 Prolonged pregnancy

  • Grade C
  • 61

Consider offering membrane sweeping to women scheduled for formal induction of labour for prolonged pregnancy.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • KKK

It may be advisable to avoid membrane sweeping before 40 weeks or in women at greater risk of Group B streptococcus.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • LLL

Women should be advised to be vigilant of a change (reduction) in fetal movements between 41 and 42 weeks.

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

  • Practice point
  • MMM

From 41 weeks, it may be reasonable to offer twice weekly cardiotocography and ultrasound to assess amniotic fluid index for surveillance of fetal well-being. 

Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW

Last updated: 
20 November 2018