Introduction

This chapter focuses on aspects of the ‘antenatal check’ undertaken by the midwife that monitor the physical wellbeing of the pregnant woman. Previous chapters have examined the procedure and rationale for some of the clinical activities undertaken by the midwife to assess the woman’s health status. During assessment of maternal physical health, the midwife will undertake an evaluation of her emotional wellbeing, and issues surrounding this aspect of care will be considered in further detail in the following chapter. Aspects of the examination that address assessment of fetal wellbeing, including abdominal palpation, will be discussed in Chapter 9.

The antenatal check

The National Institute for Health and Clinical Excellence has published recommendations regarding the content and frequency of antenatal appointments (NICE 2008) and these are summarized in Table 5.1. It is recommended that, following their initial contact with a health professional to confirm pregnancy, nulliparous women should have 10 antenatal appointments and multiparous women should have seven (NICE 2008:50). A large national survey of women’s experience of maternity care (Redshaw et al 2006) reported that there was little difference between the number of antenatal checks for women who had babies before, with an overall average of 10 checks.

**Table 5.1** Schedule of antenatal appointments and content
When	Primparous	Multiparous
First contact with a health professional: confirmation of pregnancy
Booking (by 10 weeks)	Blood tests for blood group, rhesus factor, anaemia, haemoglobinopathies, red-cell alloantibodies, hepatitis B virus, HIV, rubella antibodies and syphylis	Blood tests for blood group, rhesus factor, anaemia, haemoglobinopathies, red-cell alloantibodies, hepatitis B virus, HIV, rubella antibodies and syphylis
	Offer dating and anomaly scans and information on antenatal screening tests	Offer dating and anomaly scans and information on antenatal screening tests
16 weeks	Blood pressure and urinalysis	Blood pressure and urinalysis
	Review screening tests	Review screening tests
	Information giving	Information giving
25 weeks	Blood pressure and urinalysis
	Information giving
	Symphysis–fundal height
28 weeks	Blood pressure and urinalysis	Blood pressure and urinalysis
	Information giving	Information giving
	Symphysis–fundal height	Symphysis–fundal height
	Offer anti-D prophylaxis to rhesus negative women	Offer anti-D prophylaxis to rhesus negative women
	Screen for anaemia and atypical red-cell alloantibodies	Screen for anaemia and atypical red-cell alloantibodies
31 weeks	Blood pressure and urinalysis
	Information giving
	Symphysis–fundal height
	Review screening
34 weeks	Blood pressure and urinalysis	Blood pressure and urinalysis
	Information giving	Information giving
	Symphysis–fundal height	Symphysis–fundal height
	Offer 2nd anti-D prophylaxis to rhesus negative women	Offer 2nd anti-D prophylaxis to rhesus negative women
36 weeks	Blood pressure and urinalysis	Blood pressure and urinalysis
	Information giving	Information giving
	Symphysis–fundal height	Symphysis–fundal height
	Check position of baby	Check position of baby
38 weeks	Blood pressure and urinalysis	Blood pressure and urinalysis
	Information giving	Information giving
40 weeks	Blood pressure and urinalysis
	Information giving
41 weeks	Blood pressure and urinalysis	Blood pressure and urinalysis
	Information giving	Information giving
	Offer a membrane sweep	Offer a membrane sweep
	Offer induction of labour	Offer induction of labour

The midwife should be mindful that the NICE Antenatal care guideline is a guideline for ‘healthy pregnant women’ and where women need more support or additional monitoring this should be scheduled accordingly. Ultimately care should be tailored to meet the needs of individual women. For example: a woman experiencing a normal second pregnancy may not need to be seen as often as a woman who has a history of infertility. However, this assumption is based on generalization. The woman expecting her second baby may have had a traumatic first birth or a sister who has had a stillbirth. She may require a lot of additional support from the professional she meets. The woman with a history of infertility may be happy and well, and content to be seen according to the usual schedule. One of the many benefits of continuity of antenatal care is that the midwife can establish and maintain relationships with women, noticing when circumstances change and when the way care is offered needs to adapt in response.

Record keeping

Throughout midwifery practice, our records facilitate effective care and can be used to repeat and confirm our assessment and plan of action with the woman. She should be shown what is written, so that it can be explained there and then, rather than her going away and wondering what it all means. At the end of the interaction, the woman should understand the implications of any findings and what happens next. Finally, she should be invited to ask any more questions.

Table 5.1 shows a schedule of antenatal appointments for primiparous and multiparous women, together with the content of the visits.

Safety

The woman attending for her antenatal check-up has probably been anticipating it (either with joy or dread) for several days beforehand. She may have thought of questions she wanted to ask or have been worried that her blood pressure might be up again. In an exploratory study, Melender & Lauri (2001) linked women’s sense of security in pregnancy with visits to the clinic, good relationships with the midwife, and screening tests. The challenge for the midwife with many women to see in a busy antenatal clinic is to enable each woman to feel that she has been treated with respect and as an individual. Staff shortages, study leave and sickness compound to make this a tall order. However, eye contact, acknowledgement and active listening will enhance the interaction, without substantially lengthening the consultation. When a woman obviously needs more time, depending on the structure of local services and her current health status, it may be possible to offer a home visit or schedule another appointment.

The woman must feel that the room is safe, that the door will not suddenly be opened and a private conversation or disclosure interrupted. She also needs to feel that the information she offers will not be passed around the staff room or to the next woman in the waiting room. She will judge this by the midwife’s interactions with her. For example, if the midwife is not telling her about the previous person or the woman who lives next door, then this will give her more confidence that the midwife will not discuss her circumstances with others either.

Emotional wellbeing

The emotions that women experience during their pregnancy are wide ranging. They may change over the duration of the pregnancy and differ between individual pregnancies. The woman may need to explore her feelings with a midwife and an opening question, such as ‘How are you feeling?’, provides such an opportunity. Emotional support is identified by Wheatley (1998:46–47) as:

all those instances where reassurance, intimacy and the knowledge that one is loved and cared for are received, when advice is either sought from or offered by someone who can be confided in and relied upon to help.

The mind and body are inextricably linked such that physical pathology may lead to emotional distress and vice versa. The midwife also needs to recognize the impact of maternal ill health on the wellbeing of the developing baby and conversely, that concern about the baby will affect the emotional health of the woman. The woman’s general activity level and sprightliness may speak volumes, not just about her physical health, but also regarding her emotional health. It is good practice to go out to the waiting room and call the woman in personally. Doing so enables the midwife to assess her mobility and her mood. We can all put on a smile but much more than that is difficult to maintain if we are feeling low. Our body gives us away by our posture and eye contact.

Activity

Identify an example of how the discovery of physical illness in the mother could lead to her emotional distress. How would you minimize its effect?

Find out what services are available in your locality for pregnant women with mental health problems.

Social activity

Showing interest in the woman, rather than just the progress of the pregnancy, demonstrates concern for her as an individual. Knowledge of what the woman is doing will also provide insight into how she is feeling. It would be inappropriate to bombard the woman with a list of probing questions, but the midwife will need to satisfy herself that she is aware of the woman’s social circumstances, particularly if she did not do the booking history at the woman’s home. Is she getting support from her partner and are they making preparations together? Does she have family and friends in the area or is the woman socially isolated?

It is also important to follow up on issues that were highlighted during the booking history. For example, if the woman smoked and showed an interest in cutting down, it is important to find out how her plans are going. She may have initially declined referral to a local support initiative, but now feels that she would like to take up the offer. If she is managing to cut down using her own willpower, support and encouragement may help her maintain her resolve.

Physical tests

Routine urinalysis

It is recommended that the woman’s urine is tested for proteinuria at each antenatal examination (NICE 2008). She is asked to provide a midstream specimen in a clean container. Although a washed out jar or bottle will suffice, a specimen bottle is more discrete and secure, and can be washed and reused throughout the pregnancy. Proteinuria is an ominous symptom of pre-eclampsia; hypertensive disease in pregnancy is the second leading cause of maternal death in this country (Lewis et al 2007). There should not be any protein in urine; however, detection of a trace of protein may be present through contamination, and does not require further action unless associated with other signs of pathology.