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

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

Table 2.3   Management of results at first and subsequent visits

Supporting resources

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