BCPHP Obstetric Guideline 19

MATERNITY CARE PATHWAY

February 2010 About The BC Maternity Care Pathway

This guideline is intended as a reference for best practice for routine prenatal care
for all women in BC. It was developed in response to recommendations of the BC
Maternity Care Enhancement Project (2004). This project called for the development of
a woman-centered pathway to outline the care that a woman can expect to receive at
each stage of her pregnancy.

The purpose of the pathway is to inform all care providers of the current evidence-
based recommendations for routine care in pregnancy to ensure that all women in
BC receive the same high standard of care regardless of their residence or service
provider or special needs. The guideline is intended for use by physicians, midwives,
nurses and other healthcare professionals who care for pregnant women. This
document does not include guidelines for additional care that some women need.

The overarching philosophy represented in this guideline is that pregnancy is a normal

physiological process and therefore any interventions offered should have known
benefits and be acceptable to pregnant women.

A companion booklet, Women’s Health: Pregnancy Passport, has been developed for
pregnant women. The Women’s Health: Pregnancy Passport provides women with
the same best practice information about the care she can expect to receive during
pregnancy, birth, and the early postpartum period. The aim is to support women to
participate fully in their care in partnership with their care provider(s). The Woman’s
Health: Pregnancy Passport allows for personal documentation of a woman’s visits
to her care provider(s) and contains a list of resources for further information. The
Woman’s Health: Pregnancy Passport complements the book, Baby’s Best Chance
B.C. Perinatal Health Program
Parents Handbook of Pregnancy and Baby Care.1
F502–4500 Oak Street
Vancouver, BC Canada V6H 3N1
Tel: (604) 875-3737 Contents
www. bcphp.ca Statement of Women-Centered Services . . . . . . . . 2
Statement of Woman-Centered Care . . . . . . . . . 2
Guiding Principles for Care of Pregnant Women . . . . . . 3
Women Who May Need Additional Care. . . . . . . . 4
Preconception . . . . . . . . . . . . . . . . 5
Routine Pregnancy Care Schedule
A. Early prenatal care 0 – 14 weeks. . . . . . . . 6
B. Routine prenatal care at each appointment . . . . 11
C. 15 – 20 weeks. . . . . . . . . . . . . . 12
D. 20 – 27 weeks. . . . . . . . . . . . . . 13
E. 28 – 36 weeks. . . . . . . . . . . . . . 13
Support provided by the
Ministry of Healthy Living and Sport F. 37 – 41 weeks . . . . . . . . . . . . . 15
G. 41+ weeks. . . . . . . . . . . . . . . 15
While every attempt has been
made to ensure that the information
Procedures / Interventions Not Routinely Recommended . . . 16
contained herein is clinically accurate Lifestyle Advice . . . . . . . . . . . . . . . . 16
and current, the BC Perinatal Health
Program acknowledges that many Additional Web Resources . . . . . . . . . . . . . 21
issues remain controversial, and
therefore may be subject to practice The Development Committee . . . . . . . . . . . . 22
interpretation.
References . . . . . . . . . . . . . . . . . 22
© BCPHP, 2010
Who Designed this Pathway? generally accepted practices and accurate information
as of publication date. However, the authors, editors,
The BC Perinatal Health Program (BCPHP)2 coordinated and publisher cannot accept any responsibility, and
the development of this document. It represents a expressly disclaim all liability, including liability for
consensus opinion, based on best evidence, of an negligence, errors, omissions, or any consequence from
interdisciplinary team of BC healthcare professionals. application of the information in this guideline. This
The team included family physicians, midwives, guideline is provided as is, with no warranty, express or
obstetricians, acute care and public health nurses, implied, with respect to the contents. The information
clinical experts from the six BC Health Authorities and provided in these materials is not a substitute for clinical
representatives of the Ministry of Healthy Living and judgment and should not be construed as clinical advice.
Sport. The team wants to acknowledge the invaluable
assistance they received by referring to a body of work While every attempt has been made to ensure that
produced by the UK National Institute for Health and the information contained herein is clinically accurate
Clinical Excellence (NICE).3 and current as of the publication date, the BCPHP
acknowledges that many issues remain controversial,
The quality of the recommendations in this guideline has and therefore may be subject to practice interpretation.
been determined using the criteria described by The This guidance represents the view of BCPHP, which was
Canadian Task Force on Preventive Health Care (Table 1).4 arrived at after careful consideration of the available
evidence. The guidance does not override the individual
Table 1
responsibility of healthcare professionals to make
Levels of recommendations*
decisions appropriate to the circumstances of the
Recommendation A: There is good evidence individual patient, in consultation with the patient and/or
to recommend the clinical guardian or carer.
preventive action
Recommendation B: There is fair evidence to Statement of Women-
recommend the clinical
preventive action
Centered Services
Recommendation C: The existing evidence is Women-centred services for maternity care should occur
conflicting and does not allow in the context of primary care with the recognition that
to make a recommendation for “for the majority of women pregnancy and childbirth are
or against use of the clinical normal life events. The mother and baby are placed at
preventive action; however, the centre of care, services are planned and provided
other factors may influence to meet their needs. Providing women-centred services
decision-making relies on understanding women’s preferences and needs
with respect to care. It also involves engaging women
Recommendation D: There is fair evidence to and their families (as defined by the woman) as partners
recommend against the clinical in the processes of planning, delivering and evaluating
preventive action services.6
Recommendation I: There is insufficient evidence (in
quantity or quality) to make a
recommendation; however other Statement of Woman-
factors may influence decision Centered Care
making
Core principles of woman-centred care include respect,
*Recommendations included in these guidelines have been information sharing, participation and collaboration.
adapted from the Levels and Quality of Evidence for Treatment Women, their partners and their families should always
Recommendations described in The Canadian Task Force on be treated with kindness, respect and dignity. The
Preventive Health Care5
views, beliefs and values of the woman and her family
in relation to her care and that of her baby should be
Waiver sought and respected at all times. Women should have
the opportunity to make informed decisions about their
Any procedure or clinical practice described in the care and treatment, in partnership with their healthcare
guideline should be applied by the health care provider professionals.7
under appropriate supervision in accordance with
professional standards of care. Unique circumstances
apply in each practice situation which requires sound
clinical judgment. Care has been taken to describe

2 British Columbia Perinatal Health Program

Guiding Principles for Care Information Sharing and
of Pregnant Women Informed Consent
Access: Provide a flexible, diversity-sensitive, high Information should be provided that:
quality, accessible service. Women with limited social or
financial means or geographic barriers to access, should • Can be easily understood by all women including
be supported through innovative models of prenatal those with additional needs such as physical,
care. sensory, or learning disabilities and women who do
not speak or read English
Normal birth: Support and encourage confidence • Is balanced and unbiased
in normal birth and practices that promote minimal
intervention. • Reflects current evidence
• Is supported by written information and via different
Provider choice: Give information about local services formats if available
and the care provided by family physicians, midwives,
and obstetricians, and of where the option of home birth • Is applicable to each woman’s circumstances and
is available. Support women’s right to choose her care setting for care
provider. • Provides enough time and opportunity for discussion
and questions to ensure the woman understands
Shared decision making: Enable women to make
informed decisions based on their needs in partnership • Informs women of the purpose of any test or
with their care providers in all aspects of pregnancy intervention before it is performed
and fetal health. Respect and encourage women’s • Enables women to make informed decisions
own awareness of their health and of the well-being of
their fetus. Assist women to make decisions and clarify • Fosters collaborative decision-making between the
the right of a woman to accept or decline any test or woman and the care-provider
procedure. • Respects a woman’s decisions and choices, even if
they differ from the caregiver’s recommendations
Choice of Location and Method of Birth: Support
women’s right to choose how and where they give
birth in consultation with care providers based on best Community Resources
evidence and available local resources.
Information should be provided that informs women
Continuity of Care: Provide care by one person or a about:
small team whenever possible. When possible, allow
• Where she will be seen for prenatal care and by
women the opportunity to meet other care providers
whom
who may attend the birth. When specialist consultation
or transfer of care occurs, ensure complete and effective • Where she will give birth and who her caregiver(s) in
sharing of patient information between care providers labour will be
with a system of explicit referral and communication
• How to contact her caregiver in an emergency
pathways.
situation
Team Work: Foster an interdisciplinary collaborative • How to access prenatal education and breastfeeding
model of care with a clear understanding of all information
professional roles to maximize the quality and
comprehensiveness of care.

Obstetric Guideline 19: Maternity Care Pathway 3

Women Who May Need Additional Care
This pathway is designed for all pregnant women, most of whom are healthy.

Women with the following conditions in the current pregnancy may require additional care or services or
referral to a specialist:

• Cardiac disease, including hypertension • Use of substances such as tobacco, alcohol, heroin,
marijuana, cocaine, ecstasy and amphetamines
• Renal disease
• Obesity (pre-pregnancy body mass index >30)
• Endocrine disorders or pre-existing diabetes
• Underweight (body mass index below <18.5)
• Psychiatric disorders
• Women who are particularly vulnerable (such as
• Haematological disorders
adolescents, women living in poverty or women
• Autoimmune disorders with language barriers) who lack social support
• Pharmacological therapy (anti-depressants, • Women exposed to intimate partner violence (IPV)
anticonvulsants etc.)
• Malignant disease
• History of infertility or assisted reproductive
• Chronic infections (HIV, Hep C, HSV, Hep B, etc.)
technology
• Chronic medical/surgical disorders (epilepsy,
• Multiple pregnancy
severe asthma, lupus, etc.)
• Pre-eclampsia
• Advanced maternal age (>40)
• Gestational diabetes requiring insulin
• Other conditions determined by the care provider

Women who have experienced any of the following in previous pregnancies may require
additional care:

• Recurrent miscarriage • A stillbirth or neonatal death

• Preterm birth • A small-for-gestational-age infant (below 10th
percentile)
• Pre-eclampsia, HELLP syndrome or eclampsia
• A large-for-gestational-age infant (above 90th
• Rhesus isoimmunisation or other significant blood
percentile)
group antibodies
• A baby with a congenital abnormality (structural
• Gestational diabetes requiring insulin
or chromosomal)
• Puerperal psychosis
• Uterine surgery (e.g. Caesarean section,
• Grand multiparity (given birth more than 6 times) myomectomy, cone biopsy, or LEEP)
• Antenatal or postpartum haemorrhage
• Other conditions determined by the care provider

4 British Columbia Perinatal Health Program

Preconception (for all women of reproductive age)
Give information on:
• The benefits of a planned pregnancy and general good health
• Folic acid supplementation as per patient risk 8 (0.4 mg – 5 mg per day pre pregnancy)*
• Vitamin supplementation9
• Healthy diet10
• Food safety and how to reduce the risk of a food acquired infection*
• Weight management including healthy pre-pregnant weight (BMI of 19 – 27) and risks associated with
underweight, overweight and obesity11,12
• Physical activity13
• Contraception choices that meet timing of desired pregnancy
• Genetic counselling/testing as appropriate (such as Ashkenazi Jewish Panel, Thalassemia, Sickle Cell Anemia)14
• Use of medications and supplements*
• Lifestyle: including smoking cessation, alcohol consumption, substance use and Fetal Alcohol Spectrum
Disorder (FASD) prevention*
• History of communicable disease: including rubella susceptibility, varicella, sexually transmitted infections, HIV,
Herpes in woman and her partner(s)*
• Healthy sexuality*
• Appropriate specialist referrals for women with chronic medical conditions to allow for pre-pregnancy
assessment and planning
• Impact and implications of past obstetrical history on future pregnancies (i.e. prior preterm birth, prior still birth,
prior cesarean birth)
• Impact and implications of past gynecological history on future fertility and future pregnancies (i.e. cone biopsy,
fibroids, PCOS)
• Impact of pregnancy on women with a chronic medical condition (physical or mental)
• Identification of additional resources needed for women with a chronic medical condition (physical or mental)

*For more detail, refer to pages 16-20

Obstetric Guideline 19: Maternity Care Pathway 5

Routine Pregnancy Care Schedule
Documentation of Care
The British Columbia Antenatal Record Part 1 and Part 215

A. Early Prenatal Care 0 – 14 weeks (Usually requires more than one vist)

Time Sensitive
• Prenatal genetic screening for aneuploidy should be offered to all women in BC. Individualized discussion
should include risks, benefits, outcomes and access 16
• Folic Acid supplementation: Recommend - 0.4 mg – 1 mg per day; 5 mg per day for at risk women (such as
anticonvulsants, previous infant with spina bifida, pre-existing diabetes, challenges with healthy eating)17
• Estimate due date using history. Offer early ultrasound to all women, ideally between 11 and 14 weeks, as it is
a more accurate assessment of gestational age than last menstrual period with fewer pregnancies prolonged
past 41+0 weeks.18,19 If women qualify for NT ultrasound, the ultrasound will also confirm the due date
• Review use of medications and supplements
• Counsel all women for alcohol use. Assess for risk, discuss alcohol cessation/reduction, and refer to local
supports/resources as needed. Administer the TWEAK assessment and record on the Antenatal Record20, 21
• Screen all women for tobacco use and exposure. Counsel women on effects of smoking in pregnancy and
discuss cessation strategies, refer to specialized counselling and quit smoking resources. Consider and
discuss the benefits of nicotine replacement therapy with women who smoke more than 10 cigarettes a day
and who have not quit by 12 weeks of pregnancy22
• Screen all women for substance use. Refer to specialized services and resources as appropriate

Counselling Women for Genetic Screening

Women should be directed to the BC Prenatal Screening website for a thorough explanation of options for testing
and how they might respond to a positive result to complement counselling from a health professional.
http://www.bcprenatalscreening.ca/page179.htm

Women should understand that it is their choice to undertake screening for these syndromes. Information about
prenatal screening for Down syndrome, trisomy 18, and Open Neural Tube Defect should be given to pregnant
women at the first contact with a healthcare professional. This will provide the opportunity for further discussion
before embarking on screening and ensure that the appropriate early tests are performed if the woman wishes.
Specific information should include:

• The age-based risk for each woman for having a fetus with Down syndrome, trisomy 18, and Neural Tube Defect
• The available tests for each woman depending on her age and local and distant services
• The screening pathway for both screen positive and screen negative results
• The decisions that need to be made at each point along the pathway and their consequences
• The fact that screening does not provide a definitive diagnosis and a full explanation of the risk score obtained
following testing
• Information about chorionic villous sampling and amniocentesis including the risks of these procedures
• Balanced and accurate information about Down syndrome

Women with a screen positive result should have rapid access to further counselling with a knowledgeable
practitioner.23

6 British Columbia Perinatal Health Program

SIPS Serum Integrated Prenatal Screen NT Nuchal Translucency
IPS Integrated Prenatal Screen CVS Chorionic villus sampling
QUAD Measurement of second trimester serum quad markers (AFP, uE3, hCG and inhibin-A) in one blood
test

Brief Summary of Prenatal Genetic Screening Options in BC (2009):

• Women less than 35 years of age: Offer Serum Integrated Prenatal Screen (SIPS): Part 1 at 10 – 13+6 weeks
and Part 2 at 15 – 20+6 weeks. Results will be reported only after completion of both tests. Accurate dating of
pregnancy is important and early dating US at 10 – 11 weeks is helpful. For women who access care after 13
weeks gestation offer Quad screening (between 15 – 20+6 weeks). Offer women who access care at 15 – 20+6
weeks Maternal Serum AFP only.
• Women age 35-39: Offer Integrated Prenatal Screening (IPS = SIPS plus Nuchal Translucency) if NT is available.
Timeframe for NT is 11–13+6 weeks (optimum 12–13+3 weeks). If NT is not available offer SIPS. Women age
35-39 are no longer offered amniocentesis without prior serum screening unless they present late in the
pregnancy for care. For women who present for care after 21 weeks with no prior screening offer detailed US and
amniocentesis.
• Women age 40 or more: Offer any one of: SIPS, IPS , CVS or amniocentesis depending on local resources and
the woman’s preference.
• All women: Offer detailed US at 18 – 20 weeks.
• Women with multiple gestation: offer IPS if available and under 13+6, or if not available offer SIPS; if presenting
later than 13+6 offer Quad. Offer amniocentesis to women with screen higher than cut off, or age 35 or older.
• See below for more details.
Detailed Summary of Prenatal Genetic Screening Options in BC

Screening Options Available Through the BC Prenatal Genetic Screening Program24

Gestational Age at the First Prenatal Visit

Characteristics
of Woman >21 Weeks
<13+6 Weeks 14 – 20+6 Weeks
(no prior screening)
<35 years • SIPS (if patient is HIV+ & • Quad • Detailed ultrasound
NT is available, IPS)
35 – 39 years • SIPS; or • Quad • Detailed ultrasound; and
• If NT available, IPS • Amnio
40+ years • SIPS; or • Quad; or • Detailed ultrasound; and
• If NT available, IPS; or • Amnio without prior • Amnio
• CVS or amnio without prior screening
screening
Personal/family history that • SIPS; or • Quad; or • Detailed ultrasound; and
increases risk of fetus with • If NT available, IPS; or • Amnio without prior • Amnio
Down syndrome or trisomy 18 • CVS or amnio without prior screening
screening
Personal/family history that • CVS or amnio without prior • Amnio without prior • Detailed ultrasound; and
increases risk of fetus with screening screening • Amnio
chromosomal abnormality
other than Down syndrome or
trisomy 18
Multiple gestation • If NT available, IPS; or • Quad; or • Detailed ultrasound; and
• If NT not available, SIPS or • If >35, amnio without • If >35, amnio
if >35, amnio without prior prior screening
screening

Obstetric Guideline 19: Maternity Care Pathway 7

This guideline is being progressively implemented as NT ultrasound capacity develops throughout the province. SIPS
is now available to all pregnant women. Eligibility for IPS is changing25 and includes pregnant women 36 years or older.
When sufficient NT capacity has been developed, women 35 years old will be included. Notification will be sent when
the eligible age is reduced to 35 years old.

Positive Results
• If the prenatal screen result is screen positive for Down syndrome (assuming date is confirmed) or trisomy
18, women should be counselled by their health care practitioner and offered further diagnostic testing (e.g.
amniocentesis).
• If the prenatal screen result is screen positive for an open neural tube defect (assuming date is confirmed), women
should be referred to Medical Genetics or offered a detailed ultrasound, counselling, and if indicated diagnostic
testing.

Resources for Genetic Counselling (Medical Genetics)

• Website: http://www.bcprenatalscreening.ca/page179.htm
• Complete guideline: http://www.bcprenatalscreening.ca/sites/genetic/files/Prenatal_Screening_Guideline.pdf
• Telephone in Victoria: (250) 727-4461; Fax for referrals: (250) 727-4295
• Telephone in Vancouver: (604) 875-2157; Fax for referrals: (604) 875-3484
• Questions about prenatal screening in BC: Prenatal Biochemistry Laboratory: (604) 875-2331 (0800-1600 hrs, M-F)

First or subsequent pregnancy visits

i) Review History and Perform Physical Exam
• Discuss options for maternity care and the woman’s preference. Make referrals as appropriate
• Discuss woman’s adjustment to pregnancy (mood, work, stress, family)
• Review health history and complete Part 1 on the Antenatal Record
• Record height and weight and calculate pre-pregnancy BMI
• Identify women who may need additional care and discuss plan of care
• Discuss lifestyle, including use of tobacco, alcohol, and other substances
• Review sexual history and identify related risk factors
• Discuss financial, housing and other support
• Discuss nausea, vomiting and fatigue
• Discuss the importance of good oral hygiene, accessing early preventive dental care and safety of
treatment during pregnancy26
• Offer seasonal flu vaccine if available
• Perform complete physical examination including pelvic exam

8 British Columbia Perinatal Health Program

 ii) Offer diagnostic / screening tests:
Screening Test Recommendation Level of Recommendation / Comment
Blood group, rhesus Recommend in every pregnancy C Screening to prevent hemolytic disease of the newborn
D status and red cell within the first trimester and (e.g. from rhesus isoimmunization)
antibodies again at 28 weeks in Rh Lab testing results from Canadian Blood Services will
negative women with only one indicate when subsequent testing is necessary
previous type and screen done
by Canadian Blood Services 27 http://www.sogc.org/guidelines/public/133E-CPG-
September2003.pdf
Hb, MCV Recommend B Screening for both Fe deficiency anemia and
hemoglobinopathy
If CBC is abnormal, investigate for iron deficiency anemia
(ferritin) and hemoglobinopathy (Hb electrophoresis)
Consider consultation with hematologist
Consider screening father for hemoglobinopathy (CBC) 28
HIV Recommend A Screening for HIV to guide care and prevention of fetal
transfer
Rubella antibody titre Recommend if no known history B In all women for baseline in early pregnancy if exposed
of disease or immunization and non immune, and to guide recommendation regarding
postpartum vaccination for prevention in subsequent
pregnancy
http://www.sogc.org/guidelines/documents/
guiJOGC203CPG0802.pdf
http://www.cdc.gov/vaccines/pubs/preg-guide.htm
Hepatitis C testing Recommend screening to A http://www.sogc.org/guidelines/public/96E-CPG-
women with risk factors: October2000.pdf
• injection drug use (even once)
• hemodialysis
• persistent elevated AST
• receipt of blood products or
organs before 1992 or clotting
factors before 1988
• exposure to blood of high-risk
individual
• prison inmates
• HIV positive
• tattoos not carried out in
properly regulated premises
Standard Test for Recommend in every pregnancy A Screening for diagnosis and treatment/prevention/follow up
syphilis (STS) of treatment
Canadian Guidelines on Sexually Transmitted Infections29
Hepatitis B surface Recommend A Screening for guiding investigation of mother regarding liver
antigen function and care of newborn (vaccination at birth)
Other investigations: Routine screening for I SOGC Parvovirus B19 Infection in Pregnancy
such as parvovirus Toxoplasmosis, B19, mumps http://www.sogc.org/ guidelines/public/119E-CPG-
B19 serology (B19, should not be done September2002.pdf
IgG and IgG ), Offer serology testing to women B Specimens for rubella are held in Provincial Lab for 1 year –
mumps, CMV exposed to or with symptoms can request these other tests to be done if indicated without
of parvovirus, mumps or CMV obtaining a second sample
to determine prior immunity
(lgG) or current infection (IgM)

Obstetric Guideline 19: Maternity Care Pathway 9

 Screening Test Recommendation Level of Recommendation / Comment
Chlamydia screening Offer screening to all women B http://www.phac-aspc.gc.ca/std-mts/sti-its/
Recommend screening to pdf/502chlamydia-eng.pdf
women with increased risk http://www.bccdc.org/downloads/pdf/std/BC%20STI%20
factors30 Guidelines%202007.pdf
http://www.ctfphc.org/
Gonorrhoea Offer screening to all women A http://www.phac-aspc.gc.ca/std-mts/sti-its/
screening Recommend screening to pdf/506gonococcal-eng.pdf
women with increased risk http://www.bccdc.org/downloads/pdf/std/BC%20STI%20
factors31 Guidelines%202007.pdf
http://www.ctfphc.org/

Midstream urine for Recommend screening for A http://www.sogc.org/jogc/abstracts/200501_Obstetrics_2.pdf

C&S asymptomatic bacteruria in
early pregnancy and
screening in each trimester in C
women with know history of
recurrent UTI
GTT or Fasting Offer to diagnose (case finding) A Canadian Diabetes Association (CDA) recommends 75gm
Blood Glucose Type 2 Diabetes for patients GTT for diagnosing Type II diabetes
with risk factors: obesity and/or http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf
strong family history
http://www.healthypregnancybc.ca
Thyroid Stimulating Offer to all women B Subnormal levels in early pregnancy have been associated
Hormone Recommend to women with a with damage to fetal intellectual development.
history or symptoms of thyroid http://www.endo-society.org/guidelines/Current-Clinical-
disease or other conditions Practice-Guidelines.cfm
associated with thyroid disease

Pap Test Offer Pap testing if indicated B http://www.sogc.org/guidelines/public/144E–JPS-

March2004.pdf
TWEAK screening Recommend screening B Motherisk uses the TWEAK screening for assessing
for pregnancy risk- questionnaire pregnancy risk-drinking
drinking Screening is most sensitive for women interviewed during
the first 15 weeks of pregnancy32
http://www.motherisk.org/women/index.jsp

10 British Columbia Perinatal Health Program

 iii) Provide information on:
• How to access Baby’s Best Chance and Women’s Health: Pregnancy Passport
• Prenatal education
• Substance use (alcohol, tobacco, drugs – illicit and prescription – and harm reduction strategies)
• Intimate partner violence (IPV)
• Healthy weight gain (online resources www.healthypregnancyBC.ca)
• Healthy eating (including limiting caffeine intake)
• Physical activity, rest and work
• Food hygiene, including how to reduce the risk of a food acquired infection
• Discomforts of early pregnancy such as: nausea, vomiting, constipation and fatigue
• Occupational hazards
• Motor vehicle safety, safe seat belt use
• Benefits of breastfeeding
• Planning place of birth
• Labour support and doula care
• Early pregnancy loss (miscarriage).
For further information, see Lifestyle Advice and Recommended Websites for Women, pages 16 – 20.

B) Routine Prenatal Care at each Appointment

The routines listed below are common practice in BC and have been adapted from the American Family Physician
recommendations.33 Some of these procedures may be lacking evidence or under investigation for merit, thereby
controversial at this time. BCPHP will continue to monitor evidence and provide recommended changes as new
evidence indicates.

Procedure Recommendations Level of Recommendation / Comments

Blood C To detect change indicative of hypertensive disease in
pressure pregnancy
Assess Fetal Recommend that healthy women B SOGC / BCPHP Guidelines http://www.bcphp.ca//sites/
Movement without risk factors for adverse bcrcp/files/Guidelines/Obstetrics/Guideline_6.pdf
perinatal outcomes be aware of fetal
movements beginning at 26-32 weeks
and to perform a fetal movement
count if they perceive decreased
movements
Recommend daily fetal movements A
counting starting at 26 weeks to 32
weeks in all pregnancies with risk
factors for adverse outcomes, and
recommend that women who do not B
perceive six movements in an interval
of two hours seek further antenatal
testing as soon as possible
Fetal heart Offer at each visit, to confirm a viable C No evidence of other clinical or predictive values
tones fetus. Believed to provide psychological support to the mother
and enhance maternal bonding
Symphysis- Recommend measuring from B Plotting SFH on the graph is more effective in identifying
fundus height symphysis pubis to top of the fundus variances in growth
in centimetres. Plot on graph in
Antenatal Record

Obstetric Guideline 19: Maternity Care Pathway 11

 Procedure Recommendations Level of Recommendation / Comments
STIs Recommend rescreening in each B Canadian Guidelines on Sexually Transmitted Infections
trimester for women with ongoing risk http://www.phac-aspc.gc.ca/std-mts/sti-its/guide-
factors for STI aquisition: lignesdir-eng.php
Hep B, Hep C, HIV, chlamydia,
syphilis, gonorrhea34
Urinary Recommend all pregnant women B Urine dipstick for protein is more accurate when the
dipstick be assessed for proteinuria in early dipstick is performed in a laboratory, and when the value
testing for pregnancy to screen for preexisting is plus 3 or plus 4
proteinuria renal disease Urinary dipstick testing is inexpensive, easy, and widely
Recommend urinary dipstick testing C used. Its usefulness is uncertain for screening either
for screening for proteinuria when the women with hypertension or those who are at increased
suspicion of preeclampsia is low risk of preeclampsia. A negative or trace value should
not be ignored in a woman with new hypertension or
symptoms or signs suggestive of preeclampsia; 12%
of negative / trace results will be false negatives as
assessed against 24-hour proteinuria of 0.3 g/d, and,
regardless, these women may have preeclampsia without
proteinuria35
Recommend more definitive testing A For the detection of significant proteinuria, a urinary
for proteinuria (by urinary protein: protein creatinine ratio (UPCR) is preferred and is the
creatinine ratio (UPCR) or 24-hour diagnostic test of choice to confirm significant proteinuria
urine collection) when there is a found by other screening tests
suspicion of preeclampsia SOGC: Diagnosis, Evaluation, and Management of the
Hypertensive Disorders of Pregnancy36
Weight Recommend for women who are I Most women like to discuss healthy weight gain and
measurement underweight or overweight. Monitor activity throughout pregnancy37
weight relative to the individual goal Some women may not wish to be weighed regularly.
Consider recommending little to no B Since the evidence for any benefit is not strong, the
weight gain for obese women woman’s preference should be a consideration38
The evidence is mounting that obese women should
gain little if any weight. The new Institution of Medicine
guidelines may still be too generous39

C) Routine Care at 15 – 20 Weeks

Time Sensitive
15 – 17 weeks
Prenatal genetic screening refer to pages 7 – 8
18 – 20 weeks
Offer detailed ultrasound40
• Routine care as outlined in section B
• Follow-up of all tests / interventions
• Promote normal birth
• Recommend VBAC for women who are appropriate candidates.41 Counsel and provide informed consent
about the health risks and benefits of VBAC, including success factors (prior vaginal delivery, prior VBAC and
non recurring indication) and risk factors (41 weeks or more, need for cervical ripening, single-layer closure
and short inter-delivery interval of <24 months).42, 43, 44, 45, 46, 47 A thorough discussion of local resources with
informed consent should occur. Early discussion of VBAC in appropriate candidates increases planned VBAC.

12 British Columbia Perinatal Health Program

D) Routine Care at 20 – 27 Weeks

Time Sensitive
24 – 26 weeks
Offer repeat Rh antibody titre in Rh negative women
Consider screening for Gestational Diabetes48

• Perform routine care as outlined in B

• Follow-up of all tests / interventions
• Forward a copy of completed Antenatal Record (Part 1 & 2) to hospital

Provide information on:

• Signs and symptoms of preterm labour and what to do if the woman suspects she is in preterm labour
• Breastfeeding: benefits for infant and mother, recommendation of exclusive breastfeeding for six months
• Transfer of care / consultations if needed
• Travel to another community for birth if appropriate

E) Routine Care at 28 – 36 weeks

Time Sensitive

Week 28
Offer Rh Immunoglobulin to un-sensitized Rh negative women with informed consent (blood product)

Weeks 28 – 32
Administer Edinburgh Postnatal Depression Scale

Week 34
Assess fetal presentation, consider external cephalic version (ECV) if available49

Weeks 35 – 37
Offer Group B Strep screening – NB: request bacterial sensitivity if patient is penicillin allergic and at risk for
anaphylaxis50 with copy to the planned hospital
Offer suppression therapy for women with history of recurrent HSV51

• Perform routine care as outlined in section B

• Discuss woman’s adjustment to pregnancy (mood, work, stress, family)
• Follow-up of all tests/ interventions
• Repeat STI screening on women with increased risks
• Reassess diet, tobacco, alcohol and substance use, physical activity
• Antepartum non stress testing may be considered when adverse perinatal outcomes are present (B)52
• Offer anaesthesia consult if BMI >38 pre-pregnancy or at first prenatal visit53 (check with local anaesthetist
about other reasons for referral)
• Review options for VBAC if applicable. Re-evaluate risk and potential for success

Provide information on:

• Options for testing and treatment for GBS
• Normal birth54
• Preparation for labour (including latent phase) and birth including the woman’s preferences, recognition of the
signs of active labour and coping with pain
• Variations from normal birth and possible interventions

Obstetric Guideline 19: Maternity Care Pathway 13

• Labour support and doula55 care
• On-call arrangements, when and who to call when in labour
• Postnatal self-care, awareness of ‘baby blues’ and postnatal depression

Procedure/Test Recommendation Level of Recommendation / Comments

Blood group, rhesus Recommend for every C Screening to detect hemolytic disease of the newborn
D status and red cell pregnancy within the first from rhesus isoimmunization
antibodies trimester and again at 28 Lab testing results from Canadian Blood Services will
weeks in Rh negative women indicate when subsequent testing is necessary
with only one previous type
and screen done by Canadian http://www.sogc.org/guidelines/public/133E-CPG-
Blood Services56 September2003.pdf

CBC, HgB, MCV Offer re-screening for anaemia C http://www.cochrane.org/reviews/en/ab003094.html

If HgB less than 105g/l
investigate and consider iron
supplements
1-hour 50-g glucose Offer screening for gestational I Current evidence for benefit is lacking
screen for gestational diabetes. The discretion to SOGC recommends any one of the following:
diabetes (GDM) screen and how to screen is 1. screening all patients
at the discretion of the care 2. case finding: screen high risk women only
provider and the woman given 3. no screening57
the current lack of evidence for Canadian Diabetic Association recommends:
any one approach C 1. universal screening between 24 and 28 weeks’
gestation
D 2. if multiple risk factors for GDM present, screening
during first trimester and reassess during
subsequent trimesters
C 3. confirmation of GDM with 75gm GTT58
Edinburgh Postnatal Recommend the EPDS be B Detecting depression, and providing appropriate
Depression Scale (EPDS) administered to all women treatment and support at this stage is correlated with
between 28-32 weeks a reduction of postnatal depression. Screening at this
time also provides opportunity to link women at risk
of depression with appropriate care providers and
supports59
http://www.health.gov.bc.ca/library/publications/
year/2006/MHA_PerinatalDepression.pdf
Vaginal anal swab for GBS Offer all women screening B Request bacterial sensitivity if patient is penicillin
for presence of group B allergic and at risk for anaphylaxis
streptococcus (GBS) to If woman has had a previous baby affected by GBS
determine carrier status or GBS bacteriuria in this pregnancy a recto vaginal
screen is not indicated. Patient is considered to be
GBS+ 60
Suppressive therapy for Recommend Valacyclovir 500 A http://www.sogc.org/guidelines/documents/
recurrent genital HSV mg BID from 36 weeks to gui208CPG0806.pdf
delivery or Acyclovir 400 mg TID
ECV for Breech Confirm presentation with A If ECV unsuccessful, consider if woman is an
Presentation detailed ultrasound at 34 appropriate candidate for Breech Vaginal Delivery
weeks. Offer ECV if available based on resources, woman’s preference and other
risk factors61

14 British Columbia Perinatal Health Program

F) Routine Care at 37 – 41 weeks

Time Sensitive
Review and discuss Group B Strep screening results and options for antibiotic prophylaxis in labour

• Routine care as outlined in section B

• Follow-up of all tests/interventions
• Discuss woman’s adjustment to pregnancy (mood, work, stress, family)

Provide information on:

• Stillbirth and risk factors (gestational diabetes requiring insulin, and advanced maternal age >40 years)
• Induction of labour, risks and benefits based on current clinical situation
• C/S and VBAC, as needed
• Options for management of prolonged pregnancy such as sweeping of membranes
• Postnatal self-care and support, awareness of ‘baby-blues’ and postnatal depression
• Breastfeeding: the importance of feeding early, often and exclusively
• The benefits to the infant of skin-to-skin contact in the first hour of life: improves thermal regulation, decreases
morbidity and mortality of infant and increases initiation and duration of breast feeding62, 63
• Newborn care including eye prophylaxis, vitamin K prophylaxis and newborn screening tests (such as blood
spot screening, NB hearing screening)
• "Back to sleep" for infant sleep position64,65
• Infant safety – such as a safe sleeping environment,66 infant crying, prevention of shaken baby syndrome and
infant car seats

G ) 41+ weeks
• Further discussion of management of prolonged pregnancy
• In the case of a post-date pregnancy, the option of induction at 41+0 to 42+0 weeks should be discussed with
the woman, taking into account the favourability of the cervix, risk and benefits associated with induction or
awaiting spontaneous labour67
• If induction is declined, increase fetal surveillance including amniotic fluid assessment, non-stress testing and
fetal movement counting beginning at 41 weeks

Obstetric Guideline 19: Maternity Care Pathway 15

Procedures / Interventions Not Routinely Recommended
This section of the document only includes interventions formerly routinely practised that evidence now demonstrates
a negative outcome for the patient and/or fetus.

November 2009

• Routine urine dipstick testing for glycosuria is not recommended. It has high specificity but a low sensitivity. In
general if there is low sensitivity it does not make a good screening test.68
• Routine testing for Bacteria Vaginosis (BV) is not recommended. Asymptomatic women and women without
identified risk factors for preterm birth should not undergo routine screening for or treatment of bacterial
vaginosis (B).69
• Routine screening for toxoplasmosis, B19 and mumps is not recommended (B).70

Lifestyle Advice
The information listed below has been adapted from the American Family Physician recommendations for practices
in BC71. The evidence in these studies has not been graded using the criteria described by The Canadian Task Force
on Preventive Health Care (Table 1).

Refer to the reference article for details re levels of evidence used.

Topic Overview/Comments References

Air Travel Advise women air travel is safe until 36 weeks; long-haul http://wwwn.cdc.gov/travel/yellowBookCh9-
flights (over 6 hours) are associated with increased risk of PregnancyTraveling.aspx
venous thrombosis72
Consider safety of destination and duration of travel

Car travel Advise women to always wear seat belts in the car. Wear http://www.icbc.com/road_safety/pdf/Road_
the lap belt snug and low over the pelvic bones, below the Safety_Seatbelts_TS274S.pdf
baby; the shoulder belt should be worn tightly against the
chest
Advise women not to put the shoulder belt under the arm
or behind the back
Advise women not to recline the seat while travelling
because the seat belt will be too loose to provide proper
protection73
Advise women not to be the driver if she doesn’t have to
be. If she does drive, advise her to adjust the vehicle’s
front seat as far back as possible; this gives the air bag as
much room as possible in which to inflate if there is a crash

Dental Recommend women have dental care early in pregnancy Babies Best Chance
Health and continue as necessary. The current Cochrane http://www.health.gov.bc.ca/library/
review concludes there is some preliminary evidence to publications/year/2005/babybestchance.pdf
suggest that periodontal intervention may reduce adverse
pregnancy outcomes.74 Reducing high levels of S. mutans
by removing active decay and improving mother’s oral
hygiene before her baby is born prevents or delays
infection of her infant75

16 British Columbia Perinatal Health Program

Topic Overview/Comments References

Physical Advise women to refer to the Healthy Pregnancy BC www.healthypregnancyBC.ca

activity, website, a BC online resource developed for women http://www.phac-aspc.gc.ca/hp-gs/know-
rest and Recommend women start or continue moderate physical savoir/phys-eng.php
relaxation activity. Sports that may cause abdominal trauma, falls, http://www.sogc.org/guidelines/public/129E-
excessive joint stress, and scuba diving should be JCPG-June2003.pdf
avoided. Heat exposure such as hot tubs and saunas
should be avoided throughout pregnancy www.motherisk.org or 1-877-327-4636

Discuss the importance of adequate rest and relaxation for http://www.hc-sc.gc.ca/hl-vs/sex/index-eng.

overall well-being php

Hair “Use of hair products is unlikely to cause adverse fetal Canadian Family Physician – Motherisk
treatments effects. With occupational exposure of hairdressers, the Update
evidence suggests minimal systemic exposure to hair http://www.cfp.ca/cgi/content/full/54/10/1386
products; however, it is recommended that hairdressers
wear gloves to minimize exposure, work for less than 35
hours per week, and avoid standing for prolonged periods
of time. For the average pregnant woman, receiving hair
treatments 3 to 4 times during pregnancy does not appear
to increase risk of adverse effects on the fetus"76

Healthy Advise women to refer to Healthy Pregnancy BC, a BC Babies Best Chance
Eating online resource for women related to healthy eating and www.healthypregnancyBC.ca
healthy weight gain Dial-A-Dietitian: Greater Vancouver (604)
732-9191, Toll free in BC 1-800-667-3438.
Web: http://www.dialadietitian.org/
HealthLink BC: Phone: 8-1-1
Web: http://www.healthlinkbc.ca/diet.stm

Eating Well with Canada’s Food Guide http://www.hc-sc.gc.ca/fn-an/food-guide-

aliment/index-eng.php

Health Canada Food and Nutrition – Pregnancy Nutrition http://www.hc-sc.gc.ca/fn-an/nutrition/

prenatal/index-eng.php

My Food Guide is an interactive tool that will help women http://www.hc-sc.gc.ca/fn-an/food-guide-

personalize the information found in Canada’s Food Guide aliment/myguide-monguide/index-eng.php

Healthy Advise women to refer to the Healthy Pregnancy BC www.healthypregnancyBC.ca

Weight website, a BC resource developed for women on healthy BMI calculator: http://www.hc-sc.gc.ca/
weight, healthy weight gain, BMI calculation; plus fn-an/nutrition/weights-poids/guide-ld-adult/
resources for caregivers including the background paper bmi_chart_java-graph_imc_java-eng.php
Maternal Overweight, Obesity, and Excess Gestational
Weight Gain

Intimate Evidence suggests that IPV may first occur or increase http://www.bcphp.ca//sites/bcrcp/files/
Partner during pregnancy Guidelines/Obstetrics/IPVJuly2003Final.pdf
Violence http://www.cd.gov.bc.ca/women/contacts/
(IPV) th.htm

Obstetric Guideline 19: Maternity Care Pathway 17

 Topic Overview/Comments References

Food Safety Recommend attention to food hygiene to reduce the Babies Best Chance
risk of a food acquired infection including listeriosis and Listeriosis: http://www.healthlinkbc.ca/
toxoplasmosis. Recommend avoidance of fish containing healthfiles/hfile75.stm
high mercury content
Toxoplasmosis: http://www.healthlinkbc.ca/
kbase/topic/major/tn7481/descrip.htm
Fish low in mercury: http://www.
healthlinkbc.ca/healthfiles/hfile68m.stm
http://www.hc-sc.gc.ca/fn-an/nutrition/
prenatal/national_guidelines-lignes_
directrices_nationales-06g-eng.php#4

Medications, Risks and benefits for individual medications should be http://www.cfp.ca/cgi/content/full/54/5/687

over the reviewed based on the patients needs http://www.motherisk.org/prof/
counter, Reassure pregnant women suffering from the common updatesDetail.jsp?content_id=881
herbal cold about the safety of short-term use of OTC cold http://briggsdrugsinpregnancy.com
medications. These drugs, however, should not be
used indiscriminately or for extended periods of time. http://www.motherisk.org/women/herbal.jsp
Use should be confined to only those products that are
appropriate for the symptoms.77 Briggs recommends
against psuedoephedrine in pregnancy78
Recommend women use acetaminophen for analgesia.
Use of ibuprophen is not recommended79
Advise caution on the use of all herbal products as herbal
products are not regulated and have limited information
available. Motherrisk has reviewed available literature
and formed a database of frequently discussed herbs.
Motherisk recommends caution regarding the use of most
herbal preparatioins due to lack of evidence of their safe
use in pregnancy

Medications, Advise women to continue all prescribed medications until www.motherisk.org

prescription they consult with the prescribing physician or Toll free:1-877-327-4636
Women taking methadone should be advised to continue
at current dose and advice should be sought from a
practioner knowledgeable about perinatal substance use

Mental and See the guidelines available through these two BC http://www.bcwomens.ca/Services/
emotional websites HealthServices/ReproductiveMentalHealth/
well-being default.htm
http://www.bcphp.ca/List%20of%20
Guidelines.htm

18 British Columbia Perinatal Health Program

Topic Overview/Comments References

Nutritional Recommend supplementation with folic acid before www.motherisk.org or

supplements conception and throughout pregnancy; Folic acid Toll free: 1-877-327-4636
supplementation as per patient risk 80 (0.4 mg – 5 mg per
day pre pregnancy)

Recommend the use of multivitamin supplements including Goh, Y., Bollano, I.E., Einarson, T.R., &
folic acid for at least two to three months preconception Koren, G. (2006). Prenatal multivitamin
for primary prevention and throughout pregnancy and supplementation and rates of congenital
the postpartum period and as long as breastfeeding anomalies: a Meta-analysis. Journal of
continues81,82 Obstetrics and Gynaecology Canada, 28(8),
680-689
http://www.sogc.org/guidelines/documents/
guiJOGC201JCPG0712.pdf

Recommend vitamin D supplement between 400-2000 http://www.hc-sc.gc.ca/ahc-asc/media/

IU/day. Important for their own and baby’s health to advisories-avis/_2007/2007_72-eng.php
maintain adequate vitamin D stores during pregnancy and http://www.cps.ca/english/statements/II/
breastfeeding. Health Canada advises 400 IU vitamin D FNIM07-01.htm
intake during pregnancy and breastfeeding. Evidence is
accumulating that a higher intake is necessary. The CPS
recommends women consult with care provider regarding
appropriateness of a supplement of 2000 IU/day83

Iron supplements in the first trimester can cause increased http://www.ctfphc.org/

nausea and vomiting.
Evidence regarding the benefit of routine iron supplements
is inconclusive. Supplements are effective in improving the
hematologic indices of the mother. However, maternal iron
supplements do not appear to have a consistent effect on
the hematologic status of the fetus or newborn84

Recommend women limit vitamin A intake to less than

5,000 IU per day due to the risk of birth defects associated
with vitamin A

Sex Safe sexual intercourse during pregnancy is not associated Health Canada definition of Healthy
with adverse outcomes with the exception of women with Sexuality
placenta previa or other causes of bleeding http://www.hc-sc.gc.ca/hl-vs/sex/index-eng.
Recommend safe sex practices for women at increased php
risk of STI: illicit drug use, sexual contact with an infected Health Canada recommended book
individual, unprotected sex with a partner from an area of http://www.hc-sc.gc.ca/hl-vs/sex/index-eng.
high endemicity or travellers who have unprotected sex php
with individuals in endemic countries, sex trade workers,
sexually active youth with multiple partners and street-
involved youth, previous gonorrhoea or other STI

Obstetric Guideline 19: Maternity Care Pathway 19

 Topic Overview/Comments References

Substance Recommend that there is no safe time, no safe amount http://www.motherisk.org

use: alcohol Counsel women regarding alcohol use in pregnancy. or Toll free 1-877-327-4636
Assess for alcohol risk and refer to local supports/ http://www.bcphp.ca/List%20of%20
resources as needed. Administer the Tweak assessment Guidelines.htm
and record on the Antepartum Record http://www.hcip-bc.org/index.htm
Counselling women has been shown to be effective in
decreasing alcohol consumption during pregnancy
De-alcoholized beer and coolers, low alcoholic wines
contain alcohol, labels may be misleading. When taken in
large amounts may be unsafe85

Substance Advise all women of potential adverse affects of substance http://www.bcphp.ca/List%20of%20

use: illicit use including marijuana Guidelines.htm
drugs Provide counselling and referral as appropriate
Consider methadone maintenance for opioid use
Women who use illicit drugs require specialized
interventions within a harm reduction model

Substance Recommend screening all women for tobacco use Quitnow www.quitnow.ca or
use: and exposure to second-hand smoke. Offer referral to 1-877-455-2233
tobacco specialized counselling and quit smoking resources http://www.bcphp.ca//sites/bcrcp/
Consider and discuss the benefits of nicotine replacement files/Guidelines/SubstanceUse/
therapy with women who smoke more than 10 cigarettes TobaccoGuidelines.pdf
a day and who have not quit smoking by 12 weeks of
pregnancy86

Tattoos There is no information that tattoos pose an actual risk

in lower from the use of neuraxial block (spinals and epidurals)87,
back and 88, 89, 90,91 Many dermatologists do not consider tattoo ink

epidurals capable of causing a reaction once it is fixed in the tissue,

which usually takes about 6 months
There are often areas free of pigment where the needle can
be inserted
The simple device of making a small “nick” in the skin
with a needle prior to inserting the epidural needle may
decrease the risk of “coring”

Vision Care Transient changes in prescriptions are common during

pregnancy, return to previous state postpartum

Workplace Most workplaces are safe; prolonged standing, exposure http://www.ottawa.ca/residents/health/

to certain chemicals and high risk occupations (lifting families/planning/pregnancy/healthy/
heavy objects, shift work, high stress environment) may workplace_health_en.html
require workplace adaptations http://www.hrsdc.gc.ca/eng/lp/spila/wlb/
wfp/13Health_and_Safety_Provisions.shtml

20 British Columbia Perinatal Health Program

Additional Web Resources
Websites for caregivers
BC Perinatal Health Program (guidelines) www.bcphp.ca

Society of Obstetricians and Gynecologists of www.sogc.org

Canada (SOGC)
Motherisk www.mortherisk.org

Healthy Eating, Healthy Weight Gain, Healthy www.healthypregnancyBC.ca

Exercise
Healthy Choices in Pregnancy www.hcip-bc.org/index.htm

UK NICE Clinical Guidelines http://www.nice.org.uk/guidance/CG62

Institute for Clinical Systems Improvement http://www.icsi.org/prenatal_care_4/prenatal_care__

routine__full_version__2.html

Recommended Websites for Women

Topic Website
Baby’s Best Chance online www.health.gov.bc.ca/library/publications/year/2005/
(print copies available at local health unit) babybestchancepdf
Baby’s Best Chance DVD online http://www.hls.gov.bc.ca/maternal/initiatives/bbc.html
Breastfeeding – Best Start www.beststart.org/resources/
Breastfeeding – La Leche League www.groups.illc.ca/groups.php?prov=BC
Doula Support (finding a doula) www.bcdoulas.org
BC Association of Family Resource programs www.frpbc.ca
BC Health Files www.healthlinkbc.ca/kbaltindex.asp
Eating Well with Canada’s Food Guide and www.healthcanada.gc.ca/foodguide
My Food Guide
Health Canada’s Body Mass Index (BMI) calculator www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-
ld-adult/bmi_chart_java-graph_imc_java-eng.php
Healthy Eating, Healthy Weight, Healthy Exercise www.healthypregnancyBC.ca
Healthy Pregnancy www.motherisk.org
www.hcip-bc.org/index.htm
www.healthypregnancyBC.ca
Infant Crying www.purplecrying.org
Intimate Partner Violence/Safe Houses www.cd.gov.bc.ca/women/contacts/th.htm
Medication, Substance Use in Pregnancy www.motherisk.org
Canada's Physical Activity Guide to www.phac-aspc.gc.ca/pau-uap/paguide/
Healthy Active Living www.healthypregnancyBC.ca
Substance Use, Quit Smoking www.quitnow.ca

Obstetric Guideline 19: Maternity Care Pathway 21

Members of the BC Maternity Care Pathway Development
Committee
Tanya Baker, Registered Midwife Patty Keith, Regional Planning Leader, Hilary Planden, Public Health Preventive
Nelson Maternity & Paediatrics Services
Lucy Barney, Aboriginal Perinatal Nurse Vancouver Coastal Health Authority, Vancouver Island Health Authority, Victoria
Consultant Vancouver Andrew Sear, Family Medicine
BC Perinatal Health Program, Vancouver Colleen Kirkham, Family Medicine Quesnel
Karen Buhler, Family Medicine Vancouver Barbara Selwood, Perinatal Nurse
Vancouver Lily Lee, Perinatal Nurse Consultant Consultant
William Ehman, Family Medicine BC Perinatal Health Program, Vancouver BC Perinatal Health Program, Vancouver
Nanaimo Lenora Marcellus, Leader, Perinatal Janet Walker, Manager Acute Perinatal
Duncan Farquharson, Maternal/Fetal Program Development, Child, Youth and Program, Antepartum & Postpartum
Medicine Specialist Family Health BC Women’s Hospital, Vancouver
Royal Columbian Hospital, Vancouver Island Health Authority, Victoria Kim Williams, Perinatal Planning
New Westminster Erin O’Sullivan, Maternal-Women’s Health Fraser Health Authority, Surrey
Karin Gerlach, Registered Midwife Manager Marty Willms, Perinatal Planning
Prince George Ministry of Healthy Living and Sport, Interior Health Authority, Kelowna
Victoria
Patty Hallam, Preventive Services Don Wilson, Obstetrician
Interior Health Authority, Kamloops Jennifer Moore, Family Medicine Comox
Burnaby
Kathy Hydamaka, Preventive Services Deborah Ryan, Consultant
Vancouver Coastal Health Authority, Lynne Palmer, Clinical Nurse Specialist West Vancouver
Richmond Fraser Health Authority, Surrey

Taslin Janmohamed-Velani, Neonatal Rose Perrin, Regional Coordinator

Nurse Consultant MOREOB Program & Perinatal Planning
BC Perinatal Health Program, Vancouver Northern Health Authority, Prince George

References (Endnotes)
1 http://www.health.gov.bc.ca/library/ 11 http://www.healthypregnancybc.ca/sites/ 22 http://www.bcphp.ca//sites/bcrcp/
publications/year/2005/babybestchance. healthyweight/files/maternal_weight_ files/Guidelines/SubstanceUse/
pdf FINAL_mar5_09.pdf TobaccoGuidelines.pdf
2 BCPHP is situated within the Provincial 12 BMI calculator: http://www.hc-sc.gc.ca/ 23 http://www.nice.org.uk/guidance/CG62
Health Services Authority with a direct fn-an/nutrition/weights-poids/guide-ld- 24 www.bcprenatalscreening.ca
reporting relationship to its Executive adult/bmi_chart_java-graph_imc_java-eng.
Sponsor, Dr. J Christilaw who is the PHSA php 25 http://www.bcphp.ca//sites/bcrcp/files/
executive sponsor responsible provincially 13 Guidelines/Obstetrics/Guideline_17.pdf
www.healthypregnancyBC.ca
for women’s health and the Women’s 26 http://www.phabc.org/pdfcore/Dental_
Hospital and Health Sciences Center. 14 http://www.sogc.org/guidelines/
Health_Evidence_Review.pdf?NSNST_Fl
documents/gui218CPG0810.pdf
3 http://www.nice.org.uk/guidance/CG62 ood=13617af762044370ae97658977550
15 http://www.bcphp.ca/ a2e
4 http://www.ctfphc.org/
16 http://www.bcphp.ca//sites/bcrcp/files/ 27 http://www.sogc.org/guidelines/
5 http://www.ctfphc.org/
Guidelines/Obstetrics/Guideline_17.pdf public/133E-CPG-September2003.pdf
6 http://www.health.gov.bc.ca/library/ 17 http://www.sbhac.ca/pdf/SOGC%20 28 http://www.sogc.org/guidelines/
publications/year/2004/mcep_
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19 sti-its/guide-lignesdir-eng.ph
7 http://guidance.nice.org.uk/CG62 http://www.sogc.org/guidelines/
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20 its/pdf/502chlamydia-eng.pdf
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9 http://www.sogc.org/media/pdf/advisories/
21 its/pdf/secii-eng.pdf
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suppl/S1.pdf 32 http://www3.interscience.wiley.com/
10 www.healthypregnancyBC.ca
journal/119271879/abstract

22 British Columbia Perinatal Health Program

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Obstetric Guideline 19: Maternity Care Pathway 23

B.C. Perinatal Health Program
F502–4500 Oak Street Support provided by the
Ministry of Healthy Living and Sport
Vancouver, BC Canada V6H 3N1
Tel: (604) 875-3737
www. bcphp.ca

While every attempt has been made to ensure that the information contained
herein is clinically accurate and current, the BC Perinatal Health Program
acknowledges that many issues remain controversial, and therefore may be
subject to practice interpretation.

© BCPHP, 2010