Antenatal care

• First antenatal visit is recommended during the first 10 weeks of pregnancy but can be at anytime
• Must have shared care — doctor, midwife, obstetrician to check risks and develop shared care plan, including review schedule

High risk pregnancy

• Conditions that suggest woman may need extra antenatal care
• Underweight — BMI less than 18.5
• Obese — BMI more than 30
• High BP
• Diabetes, gestational diabetes
• Heart or kidney disease
• History or known rheumatic fever
• High EPDS — score of 10 or more or significant risk factors on Kimberly Mum’s Mood Scale 
• Use of alcohol and/or other drugs
• Known family and/or domestic violence
• Known to child protection services
• Recurrent miscarriages
• Uterine surgery, cone biopsy, fibroids removed

Schedule of antenatal visits

• Planned schedule of visits should consider individual woman's needs
• High risk pregnancy — may need more visits
• Minimum of 7–10 visits recommended
• Monthly until 28 weeks
• Fortnightly until confinement (sit down)
• Weekly after 38 weeks if not in regional centre

Key visits

First antenatal visit

• First visit will be long. Spend time getting to know woman, explaining what needs to be done
• Take detailed history — best way to find women who need extra care during pregnancy, labour and after birth
• Medical/midwife/obstetrician consult about risks and to develop shared care plan including review schedule
• Do routine antenatal check AND the following

Ask

Estimated date of birth (EDB)

• Use date of last normal menstrual period (LNMP) and obstetric wheel
• If unsure of calendar date for menstrual period ask was it at the same time as recent community or other event

Obstetric history

• Previous pregnancies including stillbirths, miscarriages, ectopic pregnancies, terminations
• Problems in previous pregnancies — high BP, diabetes, anaemia, infections, Group B Streptococcus (GBS), bleeding, blood clots (DVT, thromboembolism), premature rupture of membranes
• Previous births — date, place, gestation, episiotomy or tears, retained placenta, heavy bleeding
• Birth type — spontaneous vaginal birth, induction, forceps, vacuum, caesarean section
• Baby — weight, APGAR scores, birth anomalies, problems in first 6 weeks, GBS infection, breastfeeding
• After birth — infection, breast problems, blood clots (DVT, PE), depression

Medical and surgical history

• Allergies, medicines, immunisation history
• High BP, diabetes, heart disease, kidney disease, recurrent UTIs, fits, lung disease, asthma, blood clots, bleeding problems
• Mental health problems including previous perinatal depression
• Operations, problems with anaesthetics, blood transfusions

Gynaecological history

• Usual periods — how often, how long
• Recent contraception
• Any trouble getting pregnant, assisted reproduction
• Date of last cervical screening, results, any treatment for previous abnormality
• STIs, Pelvic Inflammatory Disease (PID), operations

Family history

• Medical problems in close relatives, especially diabetes, hypertension or mental health problems
• Multiple pregnancy, preterm labour or birth
• Genetic/family history problems

Social history

• Regular partner, family support, housing, money — current Centrelink support
• Domestic/family violence
• Substance use — prescribed medicines, smoking, passive smoking, chewing tobacco, alcohol, illicit drugs, herbal/natural substances
• Care of previous children, if known to child protection services

Check

• Weight, height, BMI — use pre-pregnancy weight to calculate BMI
• BP — take when seated and rested. Use manual sphygmomanometer, correct size cuff, same arm each time
• Head-to-toe exam — with attention to
• Mouth — gum disease, tooth decay
• Thyroid — feel for obvious enlargement
• Heart — heart rate, listen for heart murmur
• Chest — RR, listen for wheeze, crackles
• Breasts and nipples — abnormalities, concerns
• Abdomen — scars, masses, tenderness, size of uterus
• Legs — calf tenderness, varicose veins
• Skin — sores or infections

Do

• Edinburgh Postnatal Depression Scale (EPDS) or Kimberly Mother’s Mood Scale — see Perinatal depression and anxiety
• Pathology
• see Antenatal checklist
• If medical problems — may need other blood tests — see individual protocols
• Record on pathology forms — woman pregnant, how many weeks, any medicines, current medical conditions

• Request copy of results sent to antenatal clinic at hospital where birth planned

• Medical/midwife consult about immediate management and to plan shared antenatal care. Talk about findings from history and examination including
• Prescribed or other medicines that may need to be stopped or changed
• Medical problems needing treatment — abnormal U/A, STI, dental disease — refer to specialist for any pre-existing medical conditions

Supplements

• Give iodine oral — 150microgram, once a day throughout pregnancy. Can be in multivitamin designed for pregnancy and breastfeeding
• If woman has thyroid condition — medical consult
• Give folic acid oral — 0.4mg, once a day OR 5mg once a day if woman has diabetes, epilepsy, BMI over 30 or previous baby with neural tube defect.  Can be multivitamin designed for pregnancy and breastfeeding — until 12 weeks pregnant
• Give iron if needed — see Anaemia (weak blood) in pregnancy

Discuss

• Stage of baby’s development and healthy pregnancy — diet, exercise, avoiding smoking, alcohol and other drugs
• If smoking — talk about stopping smoking and consider offering nicotine replacement therapy (NRT) 
• Antenatal screening tests for abnormalities for the baby — see Antenatal genetic and ultrasound tests for baby
• Common discomforts — morning sickness, heartburn

Follow-up

• If LNMP unknown or unsure — refer for ultrasound — best done before 14 weeks
• Consider combining dating scan with first trimester nuchal translucency measurement
• Check results — see Table 2.3
• Refer to doctor and midwife and other multidisciplinary teams as indicated

• Refer to services or identify community support for social issues, if needed

Management of results

Supporting resources

• Due date online calculator
• Talking about tears video for clinicians