Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Vaccination and infection prevention in pregnancy
Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Maternal infection can become an obstetric emergency
Respiratory compromise, sepsis physiology, non-blanching rash, meningism, altered consciousness, severe dehydration, reduced fetal movement or preterm-labour symptoms during infection need urgent maternal and fetal assessment rather than a routine vaccine appointment.
Action: Assess airway, breathing, circulation, observations and gestation; begin the relevant emergency and infection-control pathway; contact maternity and microbiology or infectious-disease teams promptly; and assess fetal wellbeing without delaying maternal resuscitation.
Role and principles
Offer the current maternal vaccination programme at the correct gestation, distinguish safe inactivated vaccines from live-vaccine precautions, and respond promptly to infectious exposure or illness that could threaten the pregnant person or fetus.
Maternal vaccination protects two patients through different mechanisms. It reduces the pregnant person's risk of severe disease and creates antibody that crosses the placenta to protect the infant before the primary childhood schedule can work. At each offer, confirm gestation, previous doses in this pregnancy, allergy history, current acute illness, immunosuppression and the active national programme. Explain the disease, expected reactions, limitations and how the result will be recorded. A declined dose is documented and reoffered without coercion; it is not a reason to withdraw maternity care.
For the 2026 to 2027 influenza season, pregnant women in England are eligible from 1 September 2026. Use an age-appropriate inactivated injected vaccine at any gestation, including the first trimester. The live attenuated intranasal influenza vaccine is not the maternal programme product.
Practice
Two practice questions
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Obstetrics and gynaecologyOriginal SBA
Timing maternal pertussis protection
A healthy patient is 21+3 weeks pregnant, had a pertussis booster four years ago and received pertussis vaccine in a previous pregnancy. What should be offered now?
Sources and review status7 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.
wait until the pertussis or RSV window if influenza vaccine is already available, because postponement leaves avoidable time at risk. A mild intercurrent illness without fever is not usually a reason to defer, but an acutely unwell patient needs clinical assessment and vaccination after recovery.
Pertussis vaccination is offered in every pregnancy because antibody from a previous pregnancy or remote booster does not provide the intended protection for the current newborn. In 2026 the routine product is Tdap, given from 16 weeks; the optimal programme window remains 20 to 32 weeks and the fetal anomaly scan is a practical opportunity. Vaccination after 32 weeks can still benefit the mother and may provide some infant protection, so a missed window should trigger a late offer rather than abandonment. The infant still starts routine vaccines at eight weeks.
RSV vaccination is a year-round programme. Offer a single dose from 28 weeks in every pregnancy and aim for week 28 or shortly afterwards to allow antibody development and placental transfer before a possible preterm birth. Eligibility continues until delivery, but counselling should explain that a dose given very near birth may provide less passive infant protection. Pertussis, RSV and inactivated influenza vaccines can be co-administered at different injection sites; anti-D immunoglobulin does not require separation from them.
COVID-19 eligibility is campaign specific. Pregnancy does not by itself qualify someone for the spring 2026 campaign, but an eligible pregnant person, such as one who is immunosuppressed under the programme criteria, can be vaccinated at any gestation and can receive COVID-19 vaccine with other indicated vaccines. Avoid preserving an obsolete campaign rule in the record: check the current UKHSA eligibility and product instructions at the date of administration. Infection prevention still includes ventilation, hand hygiene, avoiding contact when infectious and early testing or treatment when clinically indicated.
Live attenuated vaccines require a different conversation. MMR and live varicella-containing vaccine are contraindicated during pregnancy as a precaution and are offered before conception or after birth when indicated; advise avoiding pregnancy for one month after MMR or live varicella vaccination. Inadvertent administration is not an indication for termination, and the exposure should be discussed with the relevant surveillance or specialist service. Other travel vaccines and post-exposure products require a destination-, gestation- and immune-status assessment rather than a blanket rule that no vaccine can ever be used.
Vaccination sits inside wider infection prevention. Ask about household rashes, childcare and healthcare work, travel, animal contact, food preparation and sexual exposure. Advise handwashing after contact with young children's urine or saliva, avoiding sharing utensils when feasible, safe food storage and cooking, and glove use for soil or animal waste. After varicella, measles, rubella, parvovirus or other important exposure, document the source, timing, closeness of contact, gestation, symptoms and immunity evidence, then contact maternity, microbiology, virology or UKHSA pathways promptly because tests and prophylaxis are time dependent.
When illness occurs, do not let fetal concern delay maternal stabilisation. Use standard sepsis and respiratory assessment, obtain appropriate cultures or viral testing and start pregnancy-compatible treatment according to the suspected infection. Ask about contractions, bleeding, fluid loss and fetal movements, and involve obstetrics at a threshold proportionate to gestation and severity. Report vaccine adverse events through the Yellow Card scheme when appropriate, while distinguishing temporal association from established causation and preserving future access to recommended vaccines.
Key points
Offer one inactivated influenza vaccine at any stage of pregnancy during the seasonal programme; do not delay it to combine with a later antenatal vaccine.
Offer one pertussis-containing Tdap vaccine in every pregnancy from 16 weeks, ideally between 20 and 32 weeks and commonly around the fetal anomaly scan.
Offer one RSV vaccine in every pregnancy from 28 weeks, ideally in week 28 or soon afterwards; eligibility continues until birth although very late vaccination may protect the infant less well.
Influenza, pertussis and RSV vaccines are inactivated and may be given at the same visit or at any interval from one another, each at its recommended gestation.
Pregnancy alone is not an indication for the spring 2026 COVID-19 campaign; give COVID-19 vaccine during pregnancy when the person meets the current programme eligibility, including relevant immunosuppression criteria.
Do not give MMR or live varicella vaccine routinely during pregnancy; arrange indicated vaccination before conception or after birth and seek expert advice after inadvertent administration rather than predicting fetal harm.
Ask about vaccine history, allergies, immunosuppression, occupational or travel exposure and infection contacts at booking, then recheck uptake at later appointments.
Assessment and patient selection
Seasonal influenza eligibility
Pregnancy at any gestation during the active influenza programme identifies eligibility for an injected inactivated influenza vaccine.
Pertussis window
From 16 weeks, with the strongest operational focus between 20 and 32 weeks, a pertussis-containing vaccine is due in every pregnancy.
RSV window
Reaching 28 weeks activates the year-round maternal RSV offer, ideally delivered promptly to maximise time for antibody transfer.
Live-vaccine precaution
MMR or live varicella vaccine is deferred during pregnancy and planned before conception or after birth when protection is incomplete.
Significant infectious exposure
A close contact, compatible rash or uncertain immunity may require urgent serology, public-health discussion or post-exposure management before symptoms develop.
Red flags requiring action
Breathlessness at rest, hypoxia, chest pain, confusion, hypotension or rapidly worsening fever in pregnancy requires same-day emergency assessment for severe respiratory infection or sepsis.
A vesicular rash or significant varicella or shingles exposure in a person without a reliable history of immunity needs urgent specialist risk assessment because time-sensitive post-exposure measures may be indicated.
Baseline assessment
01Vaccination record reconciliationFirst step
Why
Confirm which maternal vaccines were given, on what date and in which pregnancy before repeating or omitting a dose.
Interpretation and limitations
Pertussis and RSV are offered again in each pregnancy, whereas other catch-up decisions depend on a reliable lifelong record and current programme.
02Exposure and symptom history
Why
Define the organism, contact timing, intensity, symptoms and gestation after a potentially important infectious contact.
Interpretation and limitations
A precise timeline determines whether testing, isolation, prophylaxis or fetal surveillance can still change risk; vague reassurance may miss a narrow window.
03Targeted immunity or diagnostic testing
Why
Establish susceptibility or diagnose infection when national or specialist guidance recommends a result-based pathway.
Interpretation and limitations
Select serology, PCR or culture for the suspected infection and interpret with vaccination history and timing; broad unselected antenatal infection panels create misleading results.
04Maternal severity assessment
Why
Identify sepsis, hypoxia, dehydration or organ dysfunction when a pregnant person reports infectious symptoms.
Interpretation and limitations
Abnormal observations or deteriorating physiology mandates acute treatment and escalation irrespective of whether the infection is vaccine preventable.
Interventions
01Routine offerMatch each vaccine to gestationFirst stepA booking or later antenatal contact identifies an eligible pregnancy.+
1Check gestation, vaccine record, current programme, contraindications and whether a dose has already been given in this pregnancy.
2Offer inactivated influenza during the season, pertussis from 16 weeks and RSV from 28 weeks, using co-administration rather than delay when convenient.
3Record product, batch, route, site, date and consent or decline, then reoffer any missed maternal vaccine at subsequent appropriate contacts.
02ExposureAct before the prophylaxis window closesThe patient reports a rash illness, significant infectious contact, travel or occupational exposure.+
1Establish symptoms, timing, closeness of contact, gestation, immune status and whether the source diagnosis is confirmed.
Medicines and treatment safety
Reduces maternal influenza complications and transfers antibody that helps protect the young infant during the first months after birth.
Inactivated seasonal influenza vaccine
Give one 0.5 mL intramuscular dose of the age-appropriate inactivated seasonal vaccine at any gestation during the active programme.
Use the current season's recommended product and allergy guidance; do not substitute the live intranasal vaccine for the pregnancy programme.
Boosts maternal pertussis antibody for placental transfer and protection until the infant begins routine immunisation at eight weeks.
Tdap maternal pertussis vaccine
Give one 0.5 mL intramuscular dose from 16 weeks in every pregnancy, ideally between 20 and 32 weeks.
A dose in a previous pregnancy does not replace the current offer; later vaccination remains worthwhile when the optimal window was missed.
Generates maternal antibody that crosses the placenta and reduces severe RSV disease in early infancy.
Abrysvo maternal RSV vaccine
Give one 0.5 mL intramuscular dose from 28 weeks in every pregnancy, ideally during week 28 or soon afterwards.
Eligibility continues to birth, but explain that administration very close to delivery allows less time for protective antibody transfer.
Targets, monitoring and follow-up
Recheck maternal vaccine uptake at later antenatal contacts and after transfer of care, because a verbal offer without documented administration does not protect the infant.
Observe and treat immediate vaccine reactions according to the product and local resuscitation policy, with ready access to intramuscular adrenaline.
Give a clear route for reporting fever, rash, breathing difficulty, contractions, fluid loss or reduced fetal movement after infection or vaccination rather than attributing every symptom to a routine reaction.
Follow organism-specific laboratory results and public-health actions to completion, including contact management and any indicated fetal ultrasound or neonatal plan.
Plan postpartum MMR or varicella vaccination before discharge or through primary care when susceptibility was identified, and document the required interval before another pregnancy.
Report suspected clinically significant adverse reactions through the MHRA Yellow Card pathway while continuing evidence-based offers that remain indicated.
Special situations
Three clocks run independently
Influenza follows the seasonal programme, pertussis starts at 16 weeks and RSV starts at 28 weeks, so waiting to combine them can create avoidable delay.
Each pregnancy resets two offers
Pertussis and RSV vaccination are repeated in every pregnancy because the objective is strong antibody transfer to the infant from that pregnancy.
Inactivated does not mean ineffective
The recommended maternal vaccines cannot cause influenza, pertussis or RSV infection and use the maternal immune response to protect the newborn.
Inadvertent is not catastrophic
Accidental MMR or varicella vaccination during pregnancy prompts specialist surveillance and counselling, not an automatic prediction of fetal injury or pregnancy loss.
Exposure history is a timed test
The exact contact date and immune status can be as important as a laboratory result because some post-exposure interventions lose benefit with delay.
Common pitfalls
01
Delaying influenza vaccination until 20 or 28 weeks so that all maternal vaccines can be administered together.
02
Assuming a pertussis or RSV dose from a previous pregnancy protects the infant in the current pregnancy.
03
Telling every pregnant person that pregnancy alone guarantees eligibility for a COVID-19 campaign after national criteria have changed.
04
Administering live intranasal influenza, MMR or live varicella vaccine as though every vaccine has the same pregnancy safety profile.
05
Treating accidental live-vaccine exposure as an indication for pregnancy termination instead of obtaining current expert advice.
06
Using a reassuring fetal heart check to dismiss maternal hypoxia, sepsis physiology or an important infectious exposure.
Use hand hygiene, food-safety advice, safe management of animal or occupational exposure and prompt assessment after significant contact; vaccination does not prevent every important infection in pregnancy.
A measles-like febrile rash, rubella exposure, parvovirus exposure or new rash illness in pregnancy should be discussed promptly with maternity and infection specialists before the patient enters a shared waiting area.
Fever with uterine tenderness, fluid loss, contractions, vaginal bleeding or reduced fetal movement requires urgent obstetric assessment alongside infection management.
Anaphylaxis after vaccination is treated immediately with intramuscular adrenaline and standard resuscitation; pregnancy is not a reason to withhold lifesaving treatment.
A laboratory or public-health notification requirement never replaces direct clinical escalation when the pregnant person or fetus may be acutely unwell.
05Gestation-appropriate fetal assessment
Why
Check fetal wellbeing when maternal illness, fever, contractions or altered movements raises obstetric concern.
Interpretation and limitations
Use fetal heart assessment, CTG or ultrasound according to gestation and indication; a reassuring fetal test does not cancel treatment of severe maternal disease.
2
Use the organism-specific maternity, microbiology and public-health pathway to arrange testing, isolation advice and post-exposure treatment when indicated.
3Provide explicit warning symptoms and a contact route, and arrange fetal surveillance only when the infection or maternal course creates a recognised indication.
03Acute illnessStabilise the mother and assess the pregnancyFever, respiratory symptoms, rash, sepsis features or obstetric symptoms develop.+
1Assess maternal physiology and begin emergency treatment and infection-control measures without waiting for a complete fetal assessment.
2Involve obstetrics and assess fetal wellbeing according to gestation, severity, contractions, bleeding, fluid loss and movement history.
3Notify public health or occupational health when required and close the loop on diagnostic results, treatment, contacts and post-illness vaccination needs.