Introduction
This chapter addresses issues involved in the monitoring and assessment of a woman’s health during pregnancy. Different assessment methods are used and central to these are history taking and the significance of the booking appointment, as well as important issues concerning screening and the type of screening tests available. Palpation and its importance are included, as well as various pregnancy milestones.
The chapter discusses antenatal care from four key perspectives:
The midwife’s role as antenatal caregiver
To support and act as an advocate in partnership with the woman, providing assessment of maternal and fetal well-being and information in order to make informed decisions and emotional support. The student midwives’ curriculum has been guided by the Nursing and Midwifery Council (NMC 2012). Essential skills clusters and reference to the clusters will be highlighted below.
Antenatal assessment and monitoring
The NMC (2012) has outlined certain skills that need to be gained by student midwives. During midwifery education, modules and components studied are linked to these skills clusters. An example could be that the skill of ‘communication’ can be applied to every skill a student midwife undertakes as each skill will require sensitive communication and consent.
The booking visit
Traditionally, the booking visit took place at around 12 weeks. From a dietary and minor disorder of pregnancy point of view, contact with the midwife could be much earlier in the first trimester in order to offer support, care and advice. The National Service Framework (NSF) (DH 2004) standard 11 for maternity services suggests that the midwife should be the first port of call for the woman when she finds out she is pregnant. National Institute for Health and Clinical Excellence (NICE 2008) guidelines alongside those from Midwifery 2020 (DH 2010) surmise that each pregnant woman should receive the most current evidence available to help her to make fully informed choices regarding her care. In future, women may well see their midwife earlier than the traditional 12 weeks as government proposals stipulate that the midwife, rather than the GP, should be the first contact a woman has when pregnant (DH 2010).
I was really looking forward to my booking appointment with my midwife. I was 12 weeks pregnant and had finally started to tell all my friends and family. I hate hospitals as my mum died last year and view them as places for ill people and death. My partner and I had read about and researched the area of homebirth and had decided that if all remained well in my pregnancy, I would like to give birth at home. I was excited about discussing this with the midwife and had practical questions I wanted to ask her. When I brought this up at my booking appointment, the midwife told me that having a homebirth was out of the question for my first baby. I said that I had done my research and that this was my choice but the midwife was adamant that nobody would support me. I walked out of that appointment feeling disappointed, angry and let down.Taking a comprehensive history from a woman relies on the midwife having excellent communication skills in order to elicit important information as well as gaining the woman’s trust. For many, especially first-time mothers, this will be the only time that a woman/couple has met a midwife so this visit is an opportunity to explain the role. The booking visit will paint an overall picture of the woman’s physical, psychological and social needs. The woman can refer directly to the midwife and does not need to book in with her GP. NICE (2008) antenatal guidelines have endorsed the view that women should have access to antenatal services between 8 and 10 weeks of pregnancy in order to plan care in partnership with the midwife as well as for early consideration of screening options (NICE 2008).
McCourt (2006) undertook a qualitative study examining the antenatal booking interview and interactions between midwives and women using two models of care. It was found that case-loading midwives who look after a group of women, giving continuity of care and being on call for their births, were less hierarchical, offered more choice and information than midwives who were delivering a more conventional model of care, such as having different midwives for different stages of pregnancy and birth. Box 4.1 provides a checklist for the booking visit.
Carry a notebook for prompts to help when you start booking women, ensuring that nothing is written that may breach confidentiality.Be attentive |
Personal details (nearest relative, phone numbers) |
Menstrual history, including last menstrual period or date of egg insertion if in vitro fertilisation pregnancy |
Medical history, including any mental health illnesses |
Family history |
Known allergies |
Lifestyle, including Body Mass Index, smoking, alcohol and social drug use |
Previous birth history |
Her own mother’s birth history |
Physical examination |
Emotional issues, such as relationship difficulties or previous pregnancy losses |
Diet and nutrition, including any eating disorders |
Opening questions
The opening questions in the booking visit may be related to this pregnancy. Asking the open question ‘How are you feeling?’ can elicit a variety of responses and information such as whether the woman is experiencing nausea and vomiting, and if appropriate, information about her employment history and if this pregnancy has been planned. It is important to gain information and document it carefully, but not in such a way that a woman/couple feel that this is a box-ticking exercise. The important things to ask are as follows:
- Has she has had any vaginal bleeding?
- Has she suffered from nausea and vomiting?
- Has she had any recent contact with rubella or any other infectious diseases?
- Does she suffer from varicose veins?
- Does she use any ‘social’ drugs?
- Is she a smoker or a recent smoker? If yes, what type of tobacco and how much?
- What is her weekly alcohol intake?
- How is her home life with regard to relationships and support?
- How is her work life and does her job impact on her pregnancy?
- Does she have any religious and spiritual beliefs?
- Does she have any specific cultural issues and needs?
- Does she have any pets or live on a farm? If yes, advise on hygiene and avoidance of certain animals such as sheep in lambing season due to the risk of disease.
You may find that as the conversation progresses, you gain more information that you can use to plan the woman’s care and in your documentation. Try to build on what she is telling you and listen carefully as this will help in your questioning as the consultation continues. McCourt (2006) found that midwives had different styles of questioning during the booking visit. Some were authoritative, others were professional (information giving) and yet other had a partnership style (offering choice). Midwives who had the partnership style demonstrated most empathy as well as employing a technique of open questioning.
Frye (2004) suggests that midwives observe the woman carefully throughout history taking as well as using senses such as the sense of smell (for example, does she smell of alcohol or tobacco?), which may give clues to her lifestyle. The woman should be observed to see if there are any scars or bruises and if she displays antagonistic behaviour, in order to try to gain some insight as to why this may be.
Ask open questions |
Make eye contact |
Stay at the same level (with chairs the same height) |
Have a non-judgemental approach |
Observational skills – note any antagonism, bruising, smell of alcohol, for example |
Listen |
Empathise |
Respect choices |
It is useful to explore diet when discussing Body Mass Index (BMI). James (2002) notes that eating disorders are within the spectrum of psychiatric disorders. Chizawsky & Newton (2007) uncovered that as many as 15% of women seeking antenatal care may have a history of eating disorders such as anorexia or bulimia. If there is evidence of this, the woman may or may not need a team approach to care, perhaps including a dietician or psychologist experienced in eating disorders. By providing education on nutrition in pregnancy, the midwife may be a useful resource as well as reinforcing positive eating behaviours. Midwifery 2020 (DH 2010) reinforces the role of the midwife in meeting the public health needs of all women. This includes those women who may suffer from eating disorders or have a high BMI and are therefore classed as ‘obese’.
If the woman works, employment issues can be discussed and the woman may want to know her rights with regard to employment or self-employment. It is important that midwives give up-to-date and accurate information. Box 4.2 provides some tips concerning effective communication.
Remember, choice is personal. We all have different preferences, and empathy starts with being non-judgemental.Emotional well-being
The booking visit can be overwhelming for some women, perhaps because they are receiving a wealth of information. However, it is important to pay attention to their emotional as well as their physical health.
It is useful to explore the labour and birth experiences of the woman’s own mother and the mother of her partner as this may have an impact on her hopes and fears and what her influences are with regard to pregnancy and birth. It may encourage further discussion and will also help explore the woman’s attitudes to labour and birth. Asking about her family background may also help with exploring feeding issues and attitudes towards breastfeeding as she may come from a family who are very comfortable about breastfeeding or from a family with no close female relatives and who are uncomfortable about it.
A woman may have had a previous difficult or traumatic birth or she may have suffered a pregnancy loss. The booking visit is an opportunity for the woman to talk about a previous experience; she may be coming to the visit with previous birth issues. Holding the booking visit in the woman’s home puts the woman in control and is central to her care with you as her guest. With current pressures on our National Health Service, it has been recommended that sometimes bookings take place in a group. Although this may not be ideal, it is important to have an understanding that the booking visit may occur in a variety of places, including hospitals and children’s centres as well as in the woman’s home. It helps the midwife to assess her social circumstances and affords greater privacy, especially when asking intimate questions. If there are language barriers, it may be useful to have an interpreter, although this may give rise to confidentiality issues.
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