Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Nutrition, exercise, smoking and substance use
Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Withdrawal and intoxication can threaten two lives
Reduced consciousness, respiratory depression, chest pain after stimulants, severe alcohol withdrawal, seizures, overdose, suicidal intent or acute fetal concerns require emergency care; abrupt unsupported withdrawal from alcohol, opioids or dependence-forming medicines may also be dangerous.
Action: Assess airway, breathing, circulation, glucose, observations and gestation; call emergency and maternity teams; give indicated antidote or resuscitation treatment; and involve specialist alcohol or drug services urgently without delaying lifesaving maternal care.
Role and principles
Give practical, non-judgemental antenatal advice on food, activity and weight while identifying tobacco, alcohol or drug exposure early and connecting the pregnant person with effective, coordinated support.
Lifestyle assessment is clinical care, not a test of worth. Ask what the person usually eats and drinks, what movement is realistic, and whether they use tobacco, nicotine, alcohol, prescribed or non-prescribed medicines, cannabis, cocaine, opioids, benzodiazepines, stimulants or volatile substances. Establish frequency, quantity, route, last use, dependence symptoms, overdose history and who else is present. Use neutral language, explain confidentiality and its safeguarding limits, and create a plan that makes continued antenatal attendance easier rather than making disclosure feel punishable.
Healthy eating in pregnancy follows ordinary balanced-diet principles with additional food safety. Encourage accessible sources of vegetables and fruit, higher-fibre carbohydrates, protein, calcium and unsaturated fat, tailored for culture, budget, nausea and dietary restriction. Do not
Practice
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Obstetrics and gynaecologyOriginal SBA
Calculating daily caffeine exposure
A pregnant patient drinks two 75 mg cups of tea and one 40 mg can of cola daily and asks whether a 100 mg coffee would remain within guidance. What is the best answer?
Sources and review status9 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·
recommend weight-loss dieting during pregnancy. Discuss portion size and appropriate weight trajectory without shaming, and refer for dietetic support when diabetes, bariatric surgery, eating disorder, malabsorption, marked underweight, rapid weight change or nutritional insecurity makes standard advice insufficient.
Food-borne infection and excess vitamin or contaminant exposure matter. Use current NHS advice because product rules can change. Avoid liver and liver products and supplements containing retinol; avoid unpasteurised milk and unsafe soft cheeses, raw or undercooked meat and unsafe eggs, and prepare chilled ready-to-eat foods carefully. Wash produce and hands, separate raw meat, heat food thoroughly and observe use-by dates. Limit caffeine from all drinks, chocolate, medicines and supplements to 200 mg daily. Choose fish within current species and portion limits while retaining the nutritional benefit of appropriately selected fish.
The safest alcohol approach in pregnancy is abstinence because no level is known to be safe and fetal effects cannot be predicted for an individual. If a person drank a small amount before recognising pregnancy, explain that risk is likely to be low and advise avoiding further alcohol rather than generating alarm. Screen for dependence: morning drinking, withdrawal symptoms, loss of control and previous seizures require specialist review. A dependent person should not stop suddenly without medical support because maternal seizures, delirium and physiological instability also endanger the fetus.
Physical activity usually benefits pregnancy. The 2026 UK Chief Medical Officers' message is at least 150 minutes of moderate-intensity activity weekly, plus muscle-strengthening activity twice a week. Someone already active can generally continue while adapting intensity, hydration, heat and fall risk; someone inactive should build gradually. Avoid contact activities likely to strike the abdomen, scuba diving and exercise at altitude above 2,500 metres without acclimatisation or advice. Avoid prolonged supine exercise after 16 weeks and stop for pain, bleeding, fluid loss, dizziness, chest symptoms, calf swelling, contractions or altered fetal movement.
Tobacco smoke exposes the fetus to carbon monoxide and many toxins. Ask directly about smoking, household exposure, shisha, vaping and nicotine products, then use carbon monoxide as a supportive clinical measurement rather than an accusation. NICE recommends testing at the first antenatal appointment and at 36 weeks, with additional testing for current, recent or former smokers or a booking result of 4 ppm or more. A current smoker, someone who stopped within two weeks or a result at least 4 ppm receives an opt-out referral to specialist stop-smoking support.
Behavioural support and medication work together. Consider nicotine replacement therapy early when it helps the person stop smoking; explain that most smoking harm comes from combustion products and that NRT carries much lower risk than continuing to smoke. Match formulation and dose to cravings, review technique and remove nicotine patches before bed in pregnancy. Do not present unlicensed nicotine-containing e-cigarettes as medicinal treatment, but keep the focus on avoiding relapse to smoked tobacco and use shared, evidence-informed advice rather than refusing support.
Regular drug use needs coordinated maternity, addiction, mental-health, neonatal and safeguarding planning. Offer referral at first disclosure and identify a named clinician. Do not advise a person using opioids regularly to stop or reduce suddenly; stabilisation and any change need specialist supervision. Cocaine and other stimulants increase acute cardiovascular and placental risk; cannabis is not a safe treatment for nausea; sedatives and polysubstance use increase overdose and neonatal adaptation risks. Plan analgesia, prescribed substitution treatment, toxicology only with appropriate consent and purpose, birth care, newborn observation, feeding advice and take-home naloxone where indicated.
Key points
Discuss diet, activity, smoking, alcohol and recreational drugs compassionately at booking and revisit them when circumstances change; stigma and punitive language reduce disclosure and attendance.
Promote a varied diet with vegetables and fruit, higher-fibre starchy foods, protein and pasteurised dairy or fortified alternatives; pregnancy does not require eating for two.
Limit total caffeine to no more than 200 mg daily and follow current NHS food-safety advice on unpasteurised products, undercooked meat or eggs, liver, high-mercury fish and infection-prone chilled foods.
There is no known safe alcohol level in pregnancy and the safest approach is not to drink; reassure after a small inadvertent exposure while advising no further alcohol.
Aim for at least 150 minutes of moderate-intensity activity each week and muscle-strengthening activity twice weekly, starting gradually if previously inactive and adapting to symptoms or complications.
Test carbon monoxide at booking and 36 weeks, and at other appointments for current, recent or former smokers or when the booking reading is at least 4 ppm.
Make an opt-out stop-smoking referral for current smoking, stopping within the previous two weeks or carbon monoxide of 4 ppm or more; consider NRT with behavioural support because its risk is substantially lower than smoking.
Assessment and patient selection
Nutritional vulnerability
Food insecurity, restrictive diet, eating disorder, malabsorption, bariatric surgery or persistent vomiting identifies a need for tailored dietetic and medical assessment.
Unsafe activity symptom
Bleeding, fluid loss, regular painful contractions, cardiopulmonary symptoms or altered fetal movement during exercise requires clinical review before activity resumes.
Tobacco exposure
Self-reported smoking, a recent quit attempt, household smoke or carbon monoxide at least 4 ppm prompts supportive reassessment and usually an opt-out referral.
Alcohol dependence
Withdrawal symptoms, morning use, impaired control, high tolerance or a previous withdrawal seizure indicates that unsupervised cessation could be dangerous.
High-risk drug pattern
Daily opioid use, stimulant binges, injecting, overdose, polysubstance use or dependence-forming prescriptions requires rapid specialist and maternity coordination.
Red flags requiring action
Syncope, chest pain, severe breathlessness, vaginal bleeding, fluid loss, painful contractions or reduced fetal movement during or after exercise requires urgent clinical assessment rather than advice simply to rest.
Confusion, hallucinations, tremor with autonomic instability, seizures or repeated vomiting after reduced alcohol intake suggests dangerous withdrawal and needs emergency specialist treatment.
Baseline assessment
01Diet and food-security assessmentFirst step
Why
Identify nutrient gaps, unsafe foods, financial barriers and clinical conditions that require more than population advice.
Interpretation and limitations
The useful result is a practicable plan linked to dietetic or welfare support; a checklist alone does not establish nutritional adequacy.
02Weight and clinical trajectory
Why
Recognise marked loss, excessive gain, oedema or disease that changes nutritional and activity advice.
Interpretation and limitations
Interpret serial change with pre-pregnancy BMI, gestation, vomiting, blood pressure and fetal growth; weight should not be used as a moral outcome.
03Expired-air carbon monoxide
Why
Detect recent carbon monoxide exposure and support smoking cessation conversations at booking, 36 weeks and indicated interim visits.
Interpretation and limitations
A reading of 4 ppm or more meets the NICE opt-out referral criterion, but a lower value does not exclude intermittent smoking or household exposure.
04Structured substance history
Why
Define quantity, route, timing, dependence, withdrawal, overdose and combined substances so treatment is safe.
Interpretation and limitations
Clinical history guides referral and acute risk; biological testing requires a clear purpose, consent and interpretation window and must not replace trust.
Interventions
01Routine discussionTurn broad advice into attainable actionsFirst stepThe first booking visit or a later review opens a lifestyle and wellbeing discussion.+
1Ask about diet, activity, nicotine, alcohol and drugs using private, non-judgemental language and identify material barriers to change.
2Agree one or more specific actions such as food-safety changes, caffeine reduction, gradual weekly activity or contact with a support service.
3Document the plan, provide credible resources and revisit progress and new risks without treating difficulty or relapse as failure.
02SmokingMeasure, refer and treat dependenceSmoking, recent quitting, exposure concern or carbon monoxide at least 4 ppm is identified.+
1Explain the carbon monoxide result in context and make the NICE opt-out referral to specialist pregnancy stop-smoking support.
2
Medicines and treatment safety
Controls nicotine withdrawal and cravings while avoiding the carbon monoxide and many combustion toxins produced by smoking tobacco.
Nicotine replacement therapy
Select a licensed formulation and sufficient dose with specialist behavioural support; use regularly as instructed and remove a transdermal patch before bedtime during pregnancy.
Review ongoing smoking and technique to avoid undertreatment or unintended dual exposure; product choice and dose should reflect dependence and current BNF advice.
Reverses opioid-induced respiratory depression while airway support and emergency care are arranged and is not withheld when pregnancy requires lifesaving treatment.
Nyxoid intranasal naloxone
Give 1.8 mg as one spray into one nostril immediately for suspected opioid overdose; call 999 and give a second 1.8 mg spray after 2 to 3 minutes if there is no response.
Each device contains one dose; use a new device in the alternate nostril for further doses, monitor for recurrent depression and expect possible acute withdrawal in opioid dependence.
Targets, monitoring and follow-up
Review food access, vomiting, weight trajectory and any targeted laboratory abnormality, with dietetic follow-up when a clinical or social nutritional risk persists.
Ask about activity tolerance and pregnancy complications at antenatal reviews, adapting exercise while preserving safe movement wherever possible.
Repeat carbon monoxide at 36 weeks for everyone and at other visits specified by NICE for current, recent or former smokers or a raised booking result.
Track stop-smoking referral engagement, NRT effectiveness, cravings, withdrawal and lapse without discharging the person after a missed appointment.
For alcohol or drug use, maintain a shared care plan covering prescribed treatment, urine or blood tests only when clinically justified, fetal growth, birth analgesia, neonatal observation and postnatal continuity.
Reassess overdose, self-harm, domestic abuse, exploitation, housing and child-safeguarding risk as circumstances change, sharing proportionate information through the relevant local pathway.
Special situations
Advice must be affordable
A nutritionally ideal list that ignores food access, culture, nausea or cooking facilities is less safe than a realistic plan linked to practical support.
Moderate has a talk test
During moderate activity the person breathes faster yet can still hold a conversation, which is more useful than prescribing one heart-rate target.
Carbon monoxide opens care
The measurement should invite explanation of smoking and environmental exposure, not operate as a punitive truth detector or substitute for history.
NRT removes combustion
Although nicotine exposure is not risk free, licensed replacement avoids carbon monoxide and most toxic products of tobacco burning and is much safer than smoking.
Detoxification needs physiology
For alcohol or opioids, an unsupported abrupt stop can cause severe maternal withdrawal, so the safest route is rapid specialist assessment rather than moral urgency.
Common pitfalls
01
Advising pregnancy weight-loss dieting or using shame about body size instead of discussing balanced intake and clinical risk.
02
Counting coffee alone while ignoring caffeine from tea, energy drinks, cola, chocolate, medicines and supplements.
03
Telling an inactive patient either to avoid all exercise or to begin strenuous training immediately without gradual progression.
04
Recording smoking status without carbon monoxide testing, opt-out referral or effective treatment for nicotine dependence.
05
Presenting nicotine replacement as equally harmful as smoking and thereby leaving tobacco combustion untreated.
06
Telling a person dependent on alcohol or opioids to stop immediately at home without withdrawal assessment and specialist support.
07
Using drug testing secretly or punitively, which damages engagement and may not identify the substance, timing or clinical risk accurately.
Refer regular alcohol or drug use promptly to a named specialist maternity and substance service; do not advise abrupt self-detoxification from alcohol, opioids or other dependence-forming substances.
Pinpoint pupils, slow breathing, cyanosis or reduced consciousness after opioid use is an overdose emergency; give naloxone when indicated and call emergency services.
Cocaine or other stimulant use with chest pain, severe hypertension, neurological symptoms, abdominal pain or bleeding can signal maternal cardiovascular disease or placental abruption.
Food insecurity, eating disorder, rapid weight loss, persistent vomiting, malabsorption or inability to retain fluids requires targeted medical, dietetic and social support rather than generic diet advice.
Threats, coercion, exploitation, unsafe housing or a child at risk identified during substance assessment activates the local safeguarding pathway alongside confidential treatment.
05
Targeted maternal and fetal assessment
Why
Investigate complications suggested by symptoms, nutrition, smoking or substance exposure rather than screening indiscriminately.
Interpretation and limitations
Choose blood count, electrolytes, liver tests, infection testing, ECG, fetal growth assessment or CTG from the individual risk and gestation.
Offer intensive behavioural help and consider adequately dosed NRT, teaching correct use and removal of patches before sleep.
3Repeat carbon monoxide at appropriate antenatal contacts, support household quitting and adjust treatment promptly after lapse or persistent craving.
03Substance riskCoordinate safe specialist careRegular alcohol or drug use, dependence, overdose risk or associated social harm is disclosed.+
1Assess acute intoxication, withdrawal, suicidality, violence, exploitation and obstetric symptoms, using emergency care when any is time critical.
2Refer promptly to a named specialist maternity and alcohol or drug service and avoid unsupported abrupt withdrawal from alcohol or opioids.
3Build one coordinated antenatal, birth, neonatal, mental-health and safeguarding plan that states medication, monitoring, emergency contacts and information-sharing boundaries.