Chapter 9 Antenatal Care
Aim of antenatal care
The aim is to monitor the progress of pregnancy in order to support maternal health and normal fetal development. The midwife critically evaluates the physical, psychological and sociological effects of pregnancy on the woman and her family by:
developing a partnership with the woman
providing a holistic approach to the woman’s care that meets her individual needs
promoting an awareness of the public health issues for the woman and her family
exchanging information with the woman and her family and enabling them to make informed choices about pregnancy and birth
being an advocate for the woman and her family during her pregnancy, supporting her right to choose care that is appropriate for her own needs and those of her family
recognising complications of pregnancy and appropriately referring women within the multidisciplinary team
assisting the woman and her family in their preparations to meet the demands of birth, and making a birth plan
assisting the woman in making an informed choice about methods of infant feeding and giving appropriate and sensitive advice to support her decision
offering education for parenthood within a planned programme or on an individual basis
The initial assessment (booking visit)
The purpose of this visit is to:
introduce the woman to the maternity service
share information in order to discuss, plan and implement care for the duration of the pregnancy, the birth and postnatally.
The earlier the first contact is made with the midwife, the more appropriate and valuable the advice given relating to nutrition and care of the developing fetal organs. Medical conditions, infections, smoking, alcohol and drug taking may all have a profound and detrimental effect on the fetus during this time.
Introduction to the midwifery service
The woman’s introduction to midwifery care is crucial in forming her initial impressions of the maternity service. The midwife can promote communication with the woman by:
reflecting back key words used during the discussion to encourage and facilitate exploration of what is being said.
Communication encompasses the writing of accurate, comprehensive and contemporaneous records of information given and received and the plan of care that has been agreed.
Observations
Observation of physical characteristics is also important. Posture and gait can indicate back problems or previous trauma to the pelvis. The woman may be lethargic, which could be an indication of extreme tiredness, anaemia, malnutrition or depression.
Social history
It is important to assess the response of the whole family to the pregnancy and to aim to improve health and reduce health inequalities in pregnant women and their young children. The midwife may, in partnership with the woman, advocate referral to a social worker, or to other multiprofessional agencies. Questioning about domestic abuse is important but requires discretion.
General health
General health should be discussed and advice given when required. The woman, her partner and other family members should be informed about the direct and passive effects of smoking on the baby. Alcohol abuse is less common but can affect the baby. It is recommended that women limit alcohol consumption to no more than one standard unit twice in a week.
Menstrual history
The midwife needs to know how to determine the expected date of birth (still referred to as EDD). Mothers expect this estimation while waiting for an ultrasound scan or if a scan is declined or not available. Abdominal assessment of uterine size can be made in conjunction with gestational age during the antenatal consultation. The midwife has a role in helping the woman to understand that an EDD is 1 day within a 5-week time frame during which her baby reaches term and may be born.
The EDD is calculated by adding 9 calendar months and 7 days to the date of the first day of the woman’s last menstrual period (LMP). This method assumes that:
the woman takes regular note of regularity and length of time between periods
conception occurred 14 days after the first day of the last period; this is true only if the woman has a regular 28-day cycle
the last period of bleeding was true menstruation; implantation of the zygote may cause slight bleeding.
Naegele’s rule suggests that the duration of a pregnancy is 280 days. However, controversy exists over the suitability of applying Naegele’s rule to determine EDD; therefore ultrasound scanning has become the more accurate and commonly used method for predicting the EDD. This depends on an experienced ultrasonographer being both available and accessible, and also requires the woman’s consent. Ultrasound before 14 weeks confirms the EDD; the 18–20 week scan identifies abnormalities.
If the woman has taken oral contraceptives within the previous 3 months, this may also confuse estimation of dates because breakthrough bleeding and anovular cycles lead to inaccuracies. Some women become pregnant with an intrauterine contraceptive device (IUCD) still in place. Although the pregnancy is likely to continue normally, the position of the IUCD may be determined using ultrasound techniques.
Obstetric history
In order to give a summary of a woman’s childbearing history, the descriptive terms -gravida and -para are used:
‘Gravid’ means ‘pregnant’, ‘gravida’ means ‘a pregnant woman’ and a subsequent number indicates the number of times she has been pregnant regardless of outcome.
‘Para’ means ‘having given birth’; a woman’s parity refers to the number of times that she has given birth to a child, live or stillborn, excluding miscarriages and abortions.
A grande multigravida is a woman who has been pregnant five times or more irrespective of outcome. A grande multipara is a woman who has given birth five times or more.
Any form of abortion occurring in a Rhesus negative woman requires prophylactic administration of anti-D immunoglobulin to reduce the risk of Rhesus incompatibility in a subsequent pregnancy (see Ch. 35).
Repeated spontaneous abortion (miscarriage) may indicate conditions such as genetic abnormality, hormonal imbalance or incompetent cervix. The woman may be more anxious about this pregnancy, minor disturbances in pregnancy may be exacerbated and preoccupation with the pregnancy may lead to other psychological, social or physical problems.
A risk assessment should be carried out based on the woman’s obstetric and medical history and current pregnancy. This will enable the midwife and woman to:
discuss the progress of the pregnancy
determine the frequency of antenatal visits and the location of antenatal care
identify appropriate screening techniques and other health professionals who may need to be involved.
Place of birth will also be influenced by the risk assessment but in all cases the ultimate decision is taken by the mother, who should make an informed choice (Box 9.1).
Box 9.1 Factors that may require additional antenatal surveillance or advice
Past obstetric history
• Stillbirth or neonatal death
• Baby small or large for gestational age
• Pregnancy-induced hypertension
• Two or more terminations of pregnancy
• Three or more spontaneous miscarriages
• Cervical cerclage in past or present pregnancy
• Previous caesarean section or uterine surgery
• Ante- or postpartum haemorrhage
Maternal health
Medical history
During pregnancy both the mother and the fetus may be affected by a medical condition, or a medical condition may be altered by the pregnancy; if untreated, there may be serious consequences for the woman’s health.
Physical examination
Prior to the physical examination of a pregnant woman, her consent and comfort are primary considerations. Sophisticated biochemical assessments and ultrasound investigations can enhance clinical observations.
Blood pressure
Blood pressure is taken in order to ascertain normality and provide a baseline reading for comparison throughout pregnancy.
The systolic recording may be falsely elevated if a woman is nervous or anxious; long waiting times can cause additional stress. A full bladder can also cause an increase in blood pressure.
The woman should be comfortably seated or resting in a lateral position on the couch when the blood pressure is taken. Brachial artery pressure is highest when sitting and lower when in the recumbent position.
A systolic blood pressure of 140 mmHg or diastolic pressure of 90 mmHg at booking is indicative of hypertension and will need careful monitoring during pregnancy with both midwife and obstetrician support.
Blood tests in pregnancy
The midwife should explain why blood tests are carried out to enable women to make informed choices. The midwife should be fully aware of the difference between screening and diagnostic tests, and of their accuracy, and should discuss these options with the women. Blood tests taken at the initial assessment include the ones listed in Box 9.2.
Box 9.2 Blood tests performed at initial assessment
• ABO blood group and Rhesus (Rh) factor
• Venereal Disease Research Laboratory (VDRL) test
• Investigations for other blood disorders (in women and their partners of some ethnic groups – for example, sickle-cell disease or thalassaemia)
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