Antenatal care schedule and preconception care

• Antenatal care protects both mother and baby: it is the organised set of contacts, screening, tests and advice that runs from conception to birth.
• The safest start is before conception: folic acid 400 micrograms daily, started ideally 3 months before pregnancy, plus healthy weight, no smoking or alcohol, and review of medicines. ^[2]
• NICE NG201 plans 10 routine contacts for a first pregnancy and 7 for later pregnancies, with the booking (first) contact by 10 plus 0 weeks. ^{[1] [3]}
• WHO recommends at least 8 contacts and gives their gestational timing from the first 12 weeks to 40 weeks, including one ultrasound before 24 weeks. ^[3]
• Screening at booking includes infectious diseases, fetal anomalies, blood pressure and urine at every face-to-face contact, and growth checks from 24 weeks. ^[1]
• Birth planning begins before 28 weeks and is confirmed from 28 weeks, while prolonged pregnancy is discussed from 38 weeks. ^[1]

By the end of this page you should be able to:

1. Explain why preconception care, and folic acid in particular, matters before a positive test.
2. Outline the booking visit content and the routine antenatal contact schedule (NICE and WHO versions).
3. Describe the routine clinical checks, screening tests and their gestational timing.
4. Advise on nutrition, weight, exercise, common symptoms, travel and vaccination in pregnancy.
5. Plan birth preferences with a woman from the late second trimester onward.
6. Apply low-resource adaptations where standard investigations are unavailable.

Antenatal care (sometimes called prenatal care) is the organised pathway that starts with the wish to have a baby or the first positive pregnancy test and continues until birth. It has four jobs: to pick up risks early (for both mother and baby), to prevent problems, to treat problems promptly, and to prepare the woman and her partner for birth and parenthood. ^[1]

A modern antenatal pathway is not just a series of visits. Each contact should include screening and preventive advice, a chance to ask about concerns, and continuity with the same carer where possible. NICE NG201 emphasises that care should be respectful and person-centred, and that a woman's decisions should be respected even when they differ from professional advice. ^[1]

Antenatal care is one of the most effective preventive services in medicine. WHO frames it not as "visits" but as "contacts": an active connection between a woman and a trained provider that includes clinical care, advice, and emotional support. ^[3]

Preconception care is everything done before a baby is conceived: the strongest window for prevention, because the neural tube forms very early, before most women know they are pregnant. ^[2]

Folic acid is the single most important preconception intervention. Advice is to take 400 micrograms a day, starting ideally 3 months before conception and continuing for at least the first 12 weeks of pregnancy, even where flour is fortified. ^[2] A high dose of 5 mg a day is offered for 12 weeks to anyone with an increased risk of a neural tube or other congenital malformation, such as a personal, partner's or family history; a previous affected pregnancy; type 1 or type 2 diabetes; sickle cell anaemia or thalassaemia; or medicines that affect folate (for example, antiepileptic or HIV medicines). ^[2] Women with a body mass index of 25 or more, or an increased risk of pre-eclampsia, do not need more than 400 micrograms daily unless one of those risk factors applies. ^[2]

WHO recommends smaller tablets of the same agent in pregnancy itself: 30 to 60 mg of elemental iron with 400 micrograms (0.4 mg) of folic acid daily to prevent anaemia, preterm birth and low birth weight. ^[3] Vitamin D advice is 10 micrograms (400 IU) daily in the UK; between October and March for most women, and all year for those with darker skin or little sun exposure. Pregnant women should not take cod liver oil or other supplements containing vitamin A (retinol). ^[2]

Iodine is also important before and during pregnancy. Severe iodine deficiency worsens thyroid function and fetal brain development; where iodised salt is available, daily cooking salt supplies most need. A varied diet with dairy and fish suffices in most settings. Women following restricted diets (vegan, gluten-free) may need B12, and sometimes specialist advice. ^[2]

Other preconception steps include:

• Stopping smoking and avoiding alcohol completely (there is no known safe level in pregnancy). ^[1]
• Reaching a healthy weight: weight loss is not recommended once pregnant, so the pre-pregnancy window matters most. ^[2]
• Reviewing long-term medicines with a clinician; several are unsafe (for example, some antiepileptics, ACE inhibitors, statins, warfarin, isotretinoin, methotrexate) and need planned switches.
• Checking immunity: rubella, varicella and hepatitis B status, with vaccination before pregnancy where needed. Live vaccines are deferred until after birth. ^[4]
• Screening and treating sexually transmitted infections, cervical screening and mental health optimisation.
• Checking chronic conditions are controlled (diabetes, thyroid, epilepsy, hypertension) and folate level is replete.
• Genetic counselling and carrier screening where family history warrants it.

• Are you planning a pregnancy in the next year?
• If yes: folic acid dose and start date; medicines review; smoking and alcohol; weight and blood pressure; immunity and chronic disease control.
• If no: offer contraception and still give the folic acid message, because unplanned pregnancies are common.

Antenatal care can start by self-referral or referral from any healthcare professional. ^[1] Access should be simple, with information in appropriate formats and languages. ^[1]

NICE recommends the first antenatal (booking) appointment by 10 plus 0 weeks of pregnancy. ^[1] If a woman contacts services later than 9 plus 0 weeks, the appointment should take place within 2 weeks. ^[1] Booking late is a risk marker in itself and should prompt enquiry about social, psychological or medical barriers. ^[1]

The booking visit is where most of the planning happens. It covers:

• A full history: medical, obstetric and family history, including of both biological parents; mental health; current medicines (including over-the-counter, supplements and herbal remedies); allergies; occupation; home situation and support; and lifestyle (nutrition, physical activity, smoking, alcohol, drugs). ^[1]
• Mental health screening and any safeguarding concerns (domestic abuse asked privately; female genital mutilation risk assessed sensitively). ^[1]
• Referral for obstetric or medical review when needed, and sharing information with the general practitioner with consent. ^[1]
• Risk assessment repeated at every contact: general wellbeing, concerns, plan of care, and identification of women needing additional care. ^[1]

At the first face-to-face appointment, measure height and weight and calculate body mass index, and take blood for full blood count, blood group and rhesus D status. ^[1] Screening is offered for the infectious diseases in pregnancy programme (HIV, syphilis, hepatitis B), sickle cell and thalassaemia, and the fetal anomaly screening programme; the woman may accept or decline any part. ^[1]

• First-trimester scan: between 11 plus 2 and 14 plus 1 weeks, to determine gestational age, detect multiple pregnancy and (if opted for) screen for Down, Edwards and Patau syndromes. ^[1]
• Second-trimester scan: between 18 plus 0 and 20 plus 6 weeks, to screen for fetal anomalies and determine placental location. ^[1]
• WHO recommends one ultrasound before 24 weeks for all pregnant women to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce post-term induction and improve experience. ^[3]
• Dating should be fixed by the first scan. Crown-rump length dating is accurate to plus or minus 5 to 7 days, and should not be repeated later in pregnancy. ^[1]

• Venous thromboembolism risk assessed at booking and after any hospital admission. ^[1]
• Gestational diabetes risk assessed at booking; oral glucose tolerance test between 24 plus 0 and 28 plus 0 weeks if at risk. ^[1]
• Pre-eclampsia risk assessed at booking and again in the second trimester; high-risk women are advised to take low-dose aspirin (see local/NICE hypertension guidance). ^[1]
• Fetal growth restriction risk assessed at booking and in the second trimester. ^[1]

NICE plans 10 routine antenatal appointments for nulliparous women and 7 for parous women, with the schedule varying by parity (more when needed). ^[1] Additional or longer appointments are offered for medical, social or emotional need. ^[1] The schedule is available as a printable chart. ^[1]

Key timing points embedded in the schedule: ^[1]

A full risk assessment is done at every contact. ^[1] Blood pressure is recorded at every routine face-to-face appointment with a device validated in pregnancy, and a urine dipstick for protein is offered at every routine face-to-face appointment. ^[1] Severe hypertension (160/110 mmHg or higher) needs urgent same-day secondary care referral; a first episode after 20 weeks of 140/90 mmHg or higher is referred to be seen within 24 hours. ^[1]

WHO recommends a minimum of 8 contacts, raising the older 4-visit focused model, because higher frequency is associated with fewer stillbirths. ^[3] Eight or more contacts can reduce perinatal deaths by up to 8 per 1000 births compared with 4 visits. ^[3]

The recommended gestational contacts are: ^[3]

Care should be given by trained providers in facilities or through community outreach, with task shifting where local need and regulation allow. ^[3]

The two models are complementary: NICE specifies more contacts for a high-income health service; WHO sets a global minimum and maps evidence-based interventions to each of the 8 contacts. ^{[1] [3]}

A good antenatal review includes: ^[1]

• History at booking and updates at each visit.
• Physical assessment: height, weight, BMI at booking; blood pressure and urine at every face-to-face visit; abdominal palpation for breech after 36 weeks; symphysis fundal height after 24 weeks. ^[1]
• Blood tests: full blood count, blood group and rhesus D with antibodies at booking and at 28 weeks; rhesus-negative women are offered anti-D prophylaxis at 28 weeks and anti-D immunoglobulin after any sensitising event or bleeding after 13 weeks. ^[1]
• Infectious disease screening: HIV, syphilis, hepatitis B, sickle cell and thalassaemia. ^[1]
• Ultrasound: dating/anomaly and (where offered) trisomies. ^[1]
• Fetal growth and wellbeing: risk assessment, symphysis fundal height plotted onto a growth chart, growth scans only when indicated; no routine scans after 28 weeks in an uncomplicated singleton pregnancy; fetal movement advice after 24 weeks; concerns about movements merit same-day assessment. ^[1]
• Women under 20 plus 0 weeks with hypertension, and those with new hypertension later, are managed under the hypertension-in-pregnancy pathway. ^[1]

• Gestational diabetes: risk factors assessed at booking; oral glucose tolerance test at 24 plus 0 to 28 plus 0 weeks for women at risk. ^[1]
• Pre-eclampsia: risk at booking and in the second trimester; aspirin for those at risk (under NICE hypertension in pregnancy guidance). ^[1]
• Venous thromboembolism: risk at booking and after any admission. ^[1]
• Fetal growth restriction: risk at booking and in the second trimester, with referral or extra scans if growth is slow. ^[1]

Women and babies from some minority ethnic backgrounds and deprived areas have higher risks of death and stillbirth. One UK report found maternal death rates about 4 times higher in Black women, 3 times higher in women of mixed ethnicity and 2 times higher in Asian women (excluding Chinese women) compared with White women, and higher stillbirth rates in Black and Asian babies. Women in the most deprived areas were more than 2.5 times more likely to die than those in the least deprived areas. ^[1] Risk-based extra contacts and support are therefore an equity intervention, not simply "more appointments".

Antenatal information should be individualised, evidence-based, consistent and given in suitable formats and languages. ^[1] It covers what antenatal care involves; screen tests; how the baby develops; changes in pregnancy; mental health; partner support; infections and reducing them; safe medicines; immunisation in pregnancy (influenza, pertussis or whooping cough, respiratory syncytial virus and others); and resources and peer support. ^[1]

Sleep position should be discussed: women are advised to avoid going to sleep on their back after 28 weeks, using pillows if needed, because of a possible link with late stillbirth. ^[1]

Healthy eating in pregnancy is a varied diet from the Eatwell-type food groups, with attention to foods to avoid (unpasteurised dairy, raw or undercooked meat, high-mercury fish, excess caffeine) and no "eating for two". ^[2] Myths about quantity should be addressed without judgement. ^[2]

• Folic acid: 400 micrograms daily from preconception until 12 weeks (5 mg for high-risk women). ^[2]
• Vitamin D: 10 micrograms (400 IU) daily; between October and March routinely, and all year for women with darker skin or little sun. ^[2]
• Iron: supplement if needed; WHO supplies 30 to 60 mg elemental iron daily with folate. ^[3]
• Do not take vitamin A (retinol) supplements, cod liver oil or non-pregnancy multivitamins. ^[2]
• Iodine: iodised salt and diet; specialist advice for restrictive diets. ^[2]

Weight and BMI are measured at booking. ^[2] A BMI of 30 or above at booking brings a test for gestational diabetes; a BMI of 40 or above merits referral to a specialist obesity service. ^[2] Intentional weight loss during pregnancy is not recommended. ^[2] Routine weighing is unnecessary unless there is a clinical reason (for example, diabetes, severe vomiting, thromboprophylaxis). ^[2]

Moderate activity is safe and beneficial in pregnancy. Aim for 150 minutes of moderate-intensity activity per week plus 2 sessions of muscle-strengthening, spread through the week. ^[6] If new to exercise, start with about 10 minutes a day and build up. ^[6] Swimming, brisk walking and pregnancy yoga are commonly suitable; keep cool and hydrated, eat before exercising, and stop if uncomfortable, hot or unwell. ^[6]

Avoid in pregnancy: contact and impact sports with risk of falling or abdominal trauma (hockey, rugby, mountain biking); scuba diving; and lying flat on the back for more than a few minutes in later pregnancy. ^[6] New vigorous activity is not recommended. ^[6] Physical activity can reduce risks such as gestational diabetes and pre-eclampsia and improve sleep and mood. ^[6]

Pelvic floor muscle training is part of prevention of urinary incontinence and is worth mentioning at booking. ^[1]

Mild to moderate nausea and vomiting are common and usually settle by 16 to 20 weeks; ginger is a reasonable non-drug option, and antiemetics are offered when drugs are chosen. ^[1] Heartburn is managed with lifestyle changes and, where needed, a trial of antacid or alginate. ^[1] Symptomatic vaginal discharge may need a swab, and candidiasis is treated with vaginal imidazole; sexually transmitted infections are tested for when suspected. ^[1] Pregnancy-related pelvic girdle pain warrants physiotherapy and possibly a non-rigid belt. ^[1]

Antenatal providers should also ask about alcohol and other substances at the earliest opportunity and at every visit. ^[3] Reduced fetal movements after 24 weeks need a same-day assessment. ^[1]

Most women can travel safely well into pregnancy with travel insurance covering pregnancy outcomes. ^[5] Practical points: ^[5]

• Prefer mid-pregnancy (about 4 to 6 months); nausea and fatigue make the first trimester harder, and miscarriage risk is higher then. ^[5]
• The chance of labour rises after 37 weeks (about 32 weeks with twins); airlines may refuse travel late in pregnancy and may require a medical letter after 28 weeks. ^[5]
• Long travel (more than 4 hours) increases venous thrombosis risk: drink water, move every 30 minutes, consider graduated compression stockings. ^[5]
• Ferry companies often refuse women beyond 32 weeks on standard crossings and 28 weeks on high-speed ones. ^[5]
• Avoid long car journeys where possible; take breaks and wear the seatbelt with the lap strap under the bump. ^[5]
• Take care with food and water abroad; avoid traveller's diarrhoea medicines unsuitable in pregnancy. ^[5]
• Zika: pregnant women are advised not to travel to regions with Zika transmission. ^[5]
• Malaria: pregnant women are highly susceptible; avoid travel if possible, and if unavoidable choose antimalarials advised for pregnancy (doxycycline can harm fetal teeth after 12 to 13 weeks). ^[5]

Live travel vaccines (yellow fever, MMR, BCG, oral typhoid) are not usually recommended in pregnancy; non-live (inactivated) vaccines are safe. Some live vaccines may be considered when disease risk outweighs vaccine risk. ^[5]

Vaccines recommended during pregnancy in the UK guidance used here include: ^[4]

• Seasonal influenza (inactivated): recommended in pregnancy; pregnant women are more likely to develop severe influenza complications such as pneumonia.
• Pertussis (whooping cough): given usually at 20 weeks and between 16 and 32 weeks, ideally before 32 weeks, with antibody transfer to the baby who is then protected until 8 weeks when their own vaccine is due. It can be given later if missed. ^[4]
• Respiratory syncytial virus (RSV): offered around the 28-week appointment (from 28 weeks), including up to labour. ^[4]
• Tetanus: safe if needed. ^[4]

Live vaccines (MMR, BCG, oral typhoid, yellow fever) are generally deferred until after birth; non-live vaccines are safe. ^[4] WHO also recommends tetanus toxoid for all pregnant women depending on prior vaccination exposure, to prevent neonatal tetanus mortality, and daily iron and folate for anaemia prevention. ^[3]

Because antibodies cross the placenta, the timing of maternal vaccination is what protects the newborn: give early enough to make and transfer antibodies before delivery. ^[4]

NICE recommends that before 28 weeks, staff begin to talk with the woman about birth preferences and the benefits, risks and implications of different options. ^[1] From 28 weeks onward those discussions continue and her preferences are confirmed. ^[1] After 28 weeks, information includes preparing for labour and birth, recognising active labour, coping strategies, creating a birth plan, the postnatal period, newborn care, feeding, vitamin K and newborn screening, pelvic floor exercises and mental health. ^[1] Prolonged pregnancy options are discussed from 38 weeks. ^[1]

NICE offers nulliparous women (and partners) antenatal classes covering labour and birth, supporting each other, caring for the baby, bonding and feeding. Multiparous women are offered classes if useful. ^[1] Peer support may reduce isolation and improve confidence. ^[1]

Where advanced testing is unavailable, the useful minimum is straightforward: ^[3]

• One antenatal visit per trimester at least, with the WHO model of 8 contacts where staff and outreach allow.
• A single early ultrasound before 24 weeks if any scanning is possible, for dating and anomaly detection. ^[3]
• Blood pressure with a manual cuff at every visit; urine dipstick if available.
• Tetanus toxoid vaccination and daily iron and folate for all pregnant women. ^[3]
• Risk-based screening by history: previous hypertension, diabetes, thrombosis, stillbirth.
• Referral pathways for women with severe hypertension, bleeding after 13 weeks, reduced movements, breech at term or suspected growth problems.
• Folic acid and iron distributed through antenatal and primary care contacts.

Antenatal care sits alongside preconception counselling, confirmation and dating of pregnancy, pregnancy diagnosis and physiology, diabetes in pregnancy, pre-eclampsia and hypertension in pregnancy, ectopic pregnancy, and postnatal care. These are covered in other MedGrasp topics and should be consulted for detailed management of those conditions.

• Antenatal care starts before conception where possible: folic acid 400 micrograms daily from 3 months before pregnancy to 12 weeks, and 5 mg for high-risk women. ^[2]
• The booking (first antenatal) visit is due by 10 plus 0 weeks. ^[1]
• NICE plans 10 antenatal contacts for first pregnancies and 7 for later ones; WHO sets a minimum of 8 with specified gestational timings. ^{[1] [3]}
• Screening at booking includes blood pressure, urine, full blood count, blood group and rhesus D, infectious disease screening, fetal anomaly screening and risk-based tests. ^[1]
• Ultrasound dates the pregnancy: first scan 11 plus 2 to 14 plus 1 weeks, anomaly scan 18 plus 0 to 20 plus 6 weeks; WHO adds one ultrasound before 24 weeks. ^{[1] [3]}
• Gestational diabetes is tested with an oral glucose tolerance test at 24 to 28 weeks when risk factors are present. ^[1]
• Symphysis fundal height begins after 24 weeks and breech palpation after 36 weeks. ^[1]
• Moderate exercise (150 minutes a week) is recommended; scuba diving, contact sports and prolonged supine exercise are avoided. ^[6]
• Live vaccines are deferred to after birth; flu, pertussis (before 32 weeks) and RSV (from 28 weeks) are given in pregnancy. ^{[4] [1]}
• Travel late in pregnancy is restricted by airlines and ferry companies; long journeys need DVT precautions and malaria avoidance. ^[5]
• Birth preferences are introduced before 28 weeks and confirmed from 28 weeks. ^[1]