However, much of what constitutes contemporary antenatal care throughout the world remains strongly rooted in the ‘medical’ model within which it developed. Widespread, institutionalised, routine antenatal care began less than 80 years ago, as a mass screening program, with the aim of reducing maternal and perinatal mortality, and brought ‘pregnancy’ under medical supervision and control for the first time in human history (Wagner 1994). The history and politics of antenatal care will not be discussed here. They are well articulated by many authors, such as Oakley (1984), Strong (2000), Katz Rothman (1989), Donnison (1988) and, in New Zealand, Donley (1998). What is of significance in this context are the beliefs and assumptions that continue to underpin the structure and content of various aspects of antenatal care. Traditionally, and in many contemporary contexts, antenatal care consists of a prescribed set of acts based around the clinical monitoring and screening of all pregnant women, regardless of their health or risk status. This establishment of routine antenatal care was based on the notion that pregnancy is a state of pathology, rather than of normal physiology. Oakley (1984) argues that ‘the most characteristic aspect of modern antenatal care is the clinical insistence on the probability of pathology in all childbearing’ (p 2). Over the past 80 years, technological advances have brought an ever-increasing array of screening tests and treatments, ‘most often … without proper scientific evaluation and concrete evidence of benefit’ (Villar et al 2001, p 2), although ‘few of the procedures commonly undertaken have a major impact on morbidity or mortality, and some may have no effect’ (Villar et al 2001, p 2). Further, some have been found to cause physical, emotional or social harm (Wagner 1994). Hall (2001) contends that there are ‘remarkably few antenatal measures [which] are known to be effective: these are screening for and prevention of [some] infections; prevention, detection and treatment of anaemia; detection of malpresentations so that external cephalic version can be offered; and detection, investigation, and treatment of pregnancy hypertension’. These measures clearly illustrate the scope of antenatal care from a medical perspective, and the outcomes of value that are expected from it.

Some might argue that routine antenatal care fails to meet reasonable expectations of its relevance and effectiveness. If this is indeed the case, then it may be possible to mount a case to abandon it. However, such a proposition would be inappropriate from a midwifery point of view. Maternal and perinatal morbidity and mortality are not the only outcome measures of value. There is substantial evidence that midwifery-provided continuity of care has beneficial effects on other outcome measures, such as reduced anxiety, a greater sense of control (Oakley 1992), reduced use of drugs for pain relief in labour, reduced likelihood of the need for newborn resuscitation, and greater satisfaction with antenatal, intrapartum and postnatal care (Hatem et al 2008; McCourt & Page 1996; Page et al 1999). It is extremely important that all those who provide care clearly articulate the scope and limitations of the screening and diagnostic tests used in antenatal care.

The key point here is that antenatal care is a process that consists of more than just a series of medical tests and monitoring procedures. While some of these tests may form part of the process, in the midwifery context they are not of themselves the essence of antenatal care—that is, they do not define it. Midwives need to claim and promote the potential of holistic midwifery care, and put this potential into practice in their work. For midwives, antenatal care is fundamentally about a relationship between two actively participating individuals (and the woman’s support people), who bring their respective expertise together and work to maximise the health and wellbeing of the woman and her unborn child, and to prepare for labour, birth and parenting. From the midwifery perspective, the term ‘routine antenatal care’ is perhaps a misnomer, as there is no such thing as a ‘routine’ woman. Every woman is different, and each of her pregnancy experiences is unique.

ORGANISATION OF CARE

The provision of antenatal care in Australia and New Zealand has traditionally been based on a medically defined, controlled and provided system of assessment, screening and monitoring of pregnant women, which was initiated in Britain and established in the 1920s (Hall 2001).

In Australia this remains largely unchanged, although there are increasing examples of alternative models (Reiger 2001; Tracy 2005). In particular the new legislation introduced into Federal Parliament on 23 June 2009 by Health Minister Nicola Roxon proposes to extend access to the Pharmaceutical Benefits Scheme (PBS) and the Medicare Benefits Schedule, thereby enabling midwives to provide antenatal care in the community under their own responsibility. If these legislative changes are made, they will open up the possibility of midwifery models of care as alternatives to the mainstream maternity care systems. Under the new arrangements, midwives wishing to provide care under Medicare and prescribe certain medicines under the PBS will need to demonstrate that they meet certain eligibility requirements and that they have collaborative

Auscultation of baby’s heart with electronic hand-held Sonicaid.

Reproduced with the permission of the New Zealand College of Midwives

arrangements in place, including appropriate referral pathways with hospitals and doctors to ensure that women receive coordinated care and the appropriate expertise and treatment as the clinical need arises.

In New Zealand, legislation enabling an alternative organisation of care was introduced in 1990, which enabled women to choose, and midwives to provide, full and complete maternity care for well women without referral or deferral to doctors. The regulatory framework within which this occurs is currently referred to as ‘Section 88’ of the Primary Maternity Services Notice (Ministry of Health 2007). Today, antenatal care in New Zealand is founded on the concept of a primary caregiver, known as a lead maternity carer (LMC), providing the majority of care and organising referral when care is outside the scope of practice of the LMC. See Chapter 1 for detailed discussion on the role and scope of LMCs in New Zealand.

The antenatal visit

Antenatal visits are the main mechanism for the provision of antenatal care. They are negotiated and agreed upon between the woman and the midwife, and occur at prearranged times and locations, and at regular intervals throughout the woman’s pregnancy. They are multidimensional and include several components, such as information-sharing, assessment and screening, active decision-making, and health promotion and education. Aspects of these dimensions will be illustrated and discussed throughout this chapter.

The number and timing of visits follow a pattern, which was established when the concept of antenatal care was introduced in the 1920s (Candy et al 2003). This traditional pattern of antenatal visits—four-weekly from booking until 28 weeks gestation, fortnightly until 36 weeks and weekly until birth—remains the standard of antenatal care today in Australia and New Zealand. This format has no particular scientific, medical, social or midwifery foundation, and has recently been the subject of debate and challenge. This challenge arose from the concept of ‘evidence-based practice’ and has led to the evaluation of this aspect of antenatal care (Enkin et al 2000).

Determining the ‘optimal’ number of visits in routine antenatal care is extremely difficult. This is due to the complexity of the process of pregnancy itself, the diversity of childbearing women, and the context-bound, multidimensional nature of antenatal care in general (Strong 2000). Attempts to specify a particular number of visits have been based on research which measures only biomedical outcomes, such as incidence rates of preeclampsia, low birthweight, urinary tract infections, postpartum anaemia and perinatal mortality, although some studies have surveyed maternal satisfaction (Candy et al 2003; Carroli et al 2001; Petrou et al 2003; Villar et al 2001). Current recommendations, based on these studies and other similar research, are for a schedule with a reduced number of antenatal visits. The British National Institute of Clinical Excellence (NICE) guidelines (2008) and the Australian Three Centres Consensus Guidelines on Antenatal Care Project (TCCGACP (2001) both opt for a routine, for well women, of 10 visits for women having their first baby (primiparas) and seven for those having their second or subsequent baby (multiparas). It is notable, however, that a reduction in women’s satisfaction with fewer visits, as reported in research that studied this issue, has been minimised and largely ignored in these guidelines. Arguably, this illustrates the continuing dominance of the medical model as the foundation of contemporary antenatal care.

Issues concerning the length and location of antenatal visits are context-bound in the same way as those associated with the number of visits, and the alternative options offered are equally constrained within sociopolitical limits. In the New Zealand model, the woman and midwife negotiate the length and location of visits, with each party making her respective personal and practice choices clear prior to any agreement to work together. Although there is no set optimal length for visits, enough time needs to be set aside to include discussion, assessment, decision-making and documentation of the issues, such as those included in the ‘decision point’ framework set out in this chapter. The time taken for visits will vary according to the practice styles of individual midwives, differences in the needs and personalities of women, the stage of the woman’s pregnancy, and her health status.

It is also important that the location of visits be one in which both the woman and the midwife feel relaxed and comfortable, and be available at the time most convenient to them. It needs to be safe, both personally and culturally, and afford appropriate privacy. The ideal location will be accessible and have appropriate facilities. If possible, it is valuable for the midwife to provide some of the antenatal care in the woman’s home. This may help to alter the traditional power balance between care provider and receiver, and also provides valuable insight for the midwife into the woman’s personal and social context.

A MIDWIFE’S STORY

When I arrived at the woman’s home, I was surprised to find an ashtray in every room—including the toilet! She had told me previously that no one who lived in the house smoked. She hadn’t mentioned that her grandmother, who lived close by, spent most of her time at her house, and smoked heavily. It was a delicate situation, with family relationships at stake, and required the full duration of the pregnancy to support the woman in negotiating smoke-free spaces in her own home. Visiting her at home and meeting her family gave me valuable insight into how to support the woman in making changes which would have a positive impact on her own health and that of her baby, without fracturing family relationships.

Summary points: the antenatal visit

• Negotiate frequency, location and length of visits.

• Visits should be multidimensional and include:

– information-sharing

– assessment and screening

– active decision-making

– health promotion

– education.

• Antenatal visits are more than biomedical surveillance.

INITIAL CONTACT

Initial contact between a pregnant woman and a midwife is generally by phone. This call may simply be little more than an enquiry about the availability of the midwife. It may, however, evolve into a process of establishing more-substantial contact between the two, either as a continuation of the phone call, or at a face-to-face meeting. This will represent the first meaningful exchange between the midwife and the pregnant woman. It is an opportunity for the woman to gain a first impression of the midwife—what she sounds like, her ways of practice and her availability. For the midwife, it is an opportunity to help the woman clarify what she is seeking, to share information about how she practises, and to talk about the choices that are open to the woman.

There is no common understanding about the nature of this contact, in terms of what it involves, or what its outcomes are expected to be. Women perceive its purpose in different ways. Some women are better informed about the process of arranging their care than others, and are very clear about what they want. Others have no clear understanding about the process or what will come out of it. It is the midwife’s obligation to assist the woman through this initial contact by providing a framework for understanding the exchange, and a pathway through it.

Likewise, there is no standard terminology for or description of this initial contact. It may be referred to as the ‘options’ or ‘check-out’ visit or contact (to ‘check out’ meaning to gain a first impression or initial understanding of a person or a situation), and many midwives will have their own term for it. It is not the same thing as a ‘booking’ visit. The key feature differentiating this contact from a booking is that during the initial contact process, the woman and midwife share information that will enable a decision to be made about whether they will work together. The booking visit, by contrast, occurs as a result of that decision having been made.

There is also no standard format for the process itself. While individual midwives will perceive and prioritise its various stages and content differently, it needs to include certain elements in order to be meaningful to childbearing women. For women having their first baby, the system and process are new and unknown. They will often require specific information from the midwife, and will frequently be dependent upon guidance from her; they often don’t know what they need to know, in order to make an informed decision. It is the midwife’s role to facilitate informed decision-making by women, which includes the choices they make regarding their caregiver. For a list of questions that women should have answered by a prospective caregiver, see Box 22.1.

Box 22.1 Questions to ask a midwife

Pregnancy

• Are you a member of the Australian/New Zealand College of Midwives?

• Is your practice reviewed annually, through the College Standards Review process? (New Zealand)

• How many women do you ‘book’ each month?

• Who is your back-up midwife? How do you work together?

• When will I meet her? Will I have the opportunity to get to know her?

• If I require consultation with an obstetrician or other specialist, what are my options?

• Under what circumstances would my care be transferred to hospital staff?

• Where do you provide antenatal visits?

• Between visits, are you available for me to phone for advice?

• Do you work with or refer to other healthcare professionals or support groups?

• What are your beliefs about pregnancy and birth?

Labour and birth

• Do you offer home birth? Do you have access to small birthing centres in the area?

• What hospitals do you have access to?

• What birthing options do you offer (e.g. water birth)?

• Do you come to my home when I am in labour?

• In labour, if I need care from an obstetrician, how will it be arranged?

• If this happens, what role will you play in my care?

• Under what circumstances would my care be transferred to hospital staff?

• If my labour is long, who will relieve you and provide my care?

After the birth

• How often do you visit after the birth?

• If I need or choose to be in hospital after the birth, will you visit me there?

• What will your role be and what care will you provide, in that situation?

• For how many weeks do you provide care?

• Between visits, are you available for me to phone for advice?

• Do you work with or refer to other healthcare professionals or support groups?

• What are your beliefs about breastfeeding?

(Source: Adapted from the New Zealand College of Midwives pamphlet, ‘Questions to ask when you choose a midwife’ (undated publication))

The overall intention of this process is to identify the level of compatibility between the woman and her potential midwife, in order to determine whether they can establish a constructive working relationship. Without this, effective communication can be difficult, which can lead to a breakdown in the relationship between them, and in turn create the potential for a negative impact on social or clinical outcomes. Compatibility needs to occur at three levels—the interpersonal, the professional and the practical.

The interpersonal level

Each woman and midwife pair needs to feel that there is a comfortable personal connection between them. This is first and foremost a professional relationship, and not one based on shared personal experiences or a common background. The interpersonal dynamic is about a sense of relaxation and trust, and the ability to speak a social ‘language’ that the other feels comfortable with and understands. Different midwives will suit different women, and sometimes this initial discussion will result in a decision not to work together. This may be due to character and personality variables, about which we should not be surprised. The process is about establishing an effective human relationship (even if it is professional in nature), and so it should not be regarded as a sign of failure that a woman chooses not to work with a particular midwife.

Cultural factors are also key aspects of compatibility. It is important for women to have the opportunity to evaluate the cultural awareness and sensitivity of a midwife, and be confident that the midwife will be able to advocate for her culture-specific needs or desires.

The professional level

There is variation in the context and scope of practice among midwives. This variation is due in part to differences in belief and understanding of the nature of pregnancy, birth and parenting, and reflects the midwifery philosophy that underpins their practice. Midwives may also feel more or less comfortable in a range of settings. Some work comfortably with women in an obstetric setting, while others are most comfortable in the primary, community or home-birth context. The way in which midwives practise professionally will vary according to these beliefs as well as their levels of experience, personal confidence and comfort zones, and their skills or knowledge base.

There is also variation among women in their views, beliefs and understandings of the nature of pregnancy, birth and parenting. This will influence the expectations they have and the priorities they set for the type of care their midwife will provide. For example, before choosing a caregiver, a woman planning a home birth will want to know whether her choice will fit within the scope of practice of, and be genuinely supported by, her midwife.

The practical level

There are a number of practical details of care that will need to be discussed. The first of these is the availability of the midwife to provide care for the woman’s pregnancy, birth and postnatal period. This is focused on the estimated due date (EDD).

It is appropriate for midwives to inform women about arrangements for back-up when they are unavailable to provide care, such as during regular time off or illness, or when they are with another woman. In some practices, midwives work together in loose ‘partnerships’, and arrangements may or may not be made for women to meet their back-up midwives; in others, visits with the back-up midwife are an integral part of the care. There is also a moral obligation on midwives to inform women about their plans for holidays during the period of care.

A second major issue is the time and place of antenatal care. Women and midwives need to identify whether they can organise antenatal visits at a time and place that suits. This is affected by the context in which care is provided, and by the personal choices made by individual midwives. Some midwives provide clinic-based antenatal care on set days of the week. Others may negotiate with women to visit them in their homes for some or all of the antenatal care.

A MIDWIFE’S STORY

When Ana and I first met, she was eight weeks pregnant with her first child. She told me of her plan to have an elective caesarean section; she came from a country that offered this option to all women. When asked why she feared vaginal birth so much, she recounted stories of traumatic vaginal births of women she knew. None of these were normal births. I informed her that one of my professional boundaries was to decline to work with women planning a caesarean section with no clinical indication. We talked through my reasoning. Our initial visit ended with the option of us working together on the basis of planning a normal birth, or her choosing to work with someone else. The following week she attended her prearranged appointment with an obstetrician and, after considering her options, called me to ask me to provide her maternity care. We began a journey together which eventually included a normal birth.

Summary points: initial contact

• The main purpose is to establish an equitable two-way partnership between the woman and the midwife:

– both are active decision-makers and negotiate their respective roles and responsibilities

– both need the opportunity to make choices about whether or not they will work together.

• The midwife begins learning about:

– the plans, beliefs and concerns the woman has about her pregnancy, childbirth and postnatal care

– her social, cultural and physical history and context

– issues that may make it inappropriate for her to provide care, such as when a woman has specific social or cultural needs, or an underlying medical condition that requires care and knowledge that is beyond the midwife’s personal scope of practice.

• The woman learns about:

– the midwife’s personal beliefs regarding childbirth

– her scope of practice

– her professional boundaries

– the practical arrangements that may affect the woman’s choice of caregiver

– the midwife’s personality and practice and decides whether she can trust the midwife to provide the kind of care that she wants.

• This process should function as a positive screening process for both the woman and the midwife.

• Each has the right to choose to work with the other.

• Both woman and midwife share information, and actively participate and make decisions in a negotiated partnership.

THE BOOKING VISIT

The booking visit is, essentially, the beginning of the care relationship between the midwife and the woman and her family. It is an important part of the whole context of midwifery care, and of the antenatal care component in particular. It occurs early in the pregnancy and at the woman’s home where possible, and includes the midwife, the woman, and whomever else she chooses to have with her—partner, mother, sister or friend. The purpose of this visit is to formalise the arrangements for care, and to establish a foundation for the partnership. In other words, it is about defining the nature of the relationship between the woman and the midwife, and the context and meaning of antenatal care for both of them. It will:

• have a holistic focus

• be a two-way process of information-sharing and decision-making

• review the past, identify the present and plan the future

• include the identification of health, known ill-health, and risk markers for potential ill-health, for the woman or her baby

• include practical arrangements of care, in terms of frequency, time and place.

The booking visit happens as a result of a decision being made by the woman and midwife to work together. At this point, they will have already spoken by phone, and may have met, and will know a little about each other. If the initial contact or ‘check-out’ visit was not done face to face, it is preferable that the booking visit be held off until they have had an opportunity to meet. Alternatively, the visit could begin as a check-out opportunity for both, with a clearly identified endpoint for the meeting, in order to give some time and space for the woman to consider whether or not she would like to work with that midwife. If both are comfortable with each other, they may decide to formally begin the relationship at that point.

The booking visit represents the beginning of a shared journey. It is the beginning of a relationship that will last for about 10 months (in the first instance), and encompass a special, powerful and life-changing period for the woman and her family. It is a time when many personal and private aspects of a woman’s life will become shared with the midwife. As such, the booking is a great opportunity for the midwife to get to know the woman she will be working with. The woman’s home is the ideal venue for this visit, as it is in her place and space, which can help to moderate the traditional hierarchical power dynamic between ‘healthcare professional’ and ‘patient’, to that of a more equitable partnership between midwife and woman.

Having the booking visit at the woman’s home can also give the midwife important information about the woman’s personal and social context. The midwife will be able to gain valuable insight into the woman’s personality and outlook, her understanding of pregnancy and childbirth, and her life situation and lifestyle choices, when discussing her history and her present and future plans. There is as much to be learned from the way in which the woman talks about these things, and the way she responds to new information or options, as there is from what she says. During the discussion, the midwife can develop a sense of how the woman perceives her own role in the birth process—as an active ‘doer’ or a passive ‘receiver’ of care—as well as her understanding of health issues and the concept of risk in pregnancy.

Learning about who a woman is, in a holistic sense, is a central and integral component of the midwifery model. It is not an optional extra to the ‘real’ physical or clinical aspects, but an imperative for midwifery care, if an effective working relationship is to develop. Having this understanding helps the midwife to tailor the way she shares information with the woman, so that it may be meaningful for her. Midwives cannot identify what is appropriate for women if they know nothing of their personal, social or cultural ‘self’. Sharing information or making recommendations that are irrelevant or inappropriate to their personal, social or cultural circumstances will be ineffectual, can be offensive, and may have a negative impact on the woman and the outcomes.

The booking visit and the process of establishing a partnership is not about ‘becoming friends’ or ‘being nice’.

Antenatal assessment of baby wellbeing.

Reproduced with the permission of the New Zealand College of Midwives

It is about developing an effective working relationship at a professional level, between human beings.

Reviewing the past

The quality and quantity of information shared during the booking visit depends on a number of factors. The specific questions asked by the midwife, the way in which they are asked, and the timing of them (in terms of when in the booking process they are asked), may influence a woman’s responses, particularly when they relate to sensitive information such as that regarding sexually transmitted infections, abortions or abuse.

It is also important to recognise that a woman’s knowledge of her family’s health history and that of her own childhood illnesses or operations may be limited, perhaps due to poor access to those details, possibly as a result of family separation or dislocation or such like. Some women may also have limited understanding of the details of treatments or the nature of medical procedures they have undergone. For example, the detail, meaning or significance of differing cervical treatments (such as loop surgery, cone biopsy, laser treatment and the associated terminology such as ‘CIN I, II or III’) are sometimes not known or understood by women. This means that women, understandably, are sometimes unable to provide the level of detail sought by midwives.

The midwife identifies risk markers from the woman’s history, and discusses them with her. This discussion may include options for testing, screening, treatment, self-care, referral for consultation with situation-appropriate specialists, support and further information sharing. (See Ch 33 for discussion on screening, assessment and consultation options, and Ch 34 for discussion on risk markers and potential complications in pregnancy.)

Research findings suggest that midwives who use a ‘structured paper history’ incorporating a cue sheet (see Box 22.2) are likely to get ‘more and better information’ than those using an unstructured format (NICE 2008, p 69). Documentation of shared information is very important for both the woman and the midwife. During the care, it is appropriate for the woman to carry her own maternity notes (NICE 2008, p 70). Upon completion of care, the midwife also needs to keep a copy of these documents, in order to meet her respective professional and legal requirements.

Box 22.2 Historical health review

Maternity: midwifery and obstetric

• Gravida—number of pregnancies (includes living children, miscarriage, termination of pregnancy, ectopic pregnancy, stillbirth, neonatal death)

• Parity—number of babies born at or beyond 20 weeks, preterm (< 37 weeks), post-term (> 42 weeks)

• Contraceptive history

• Past pregnancy/pregnancies—date, place, pregnancy complications, labour spontaneous/induced, gestation, duration of complications, outcome, name, sex, weight, breast/artificial feeding, postnatal complications, social/economic/cultural issues

• Other

Risk markers

• Chronic hypertension—genetic hypertension or preeclampsia (degree), gestational diabetes

• Multiple pregnancy—congenital abnormalities, antenatal anaemia (Hb < 90)

• Preterm birth (< 37 weeks)—small baby (IUGR/SGA), APH

• Post-term birth (> 42 weeks)—large baby (> 4500 g), shoulder dystocia

• Assisted birth (forceps/ventouse)—lower-segment caesarean section, vaginal birth after caesarean section, postpartum haemorrhage (> 1000 mL or treated)

• Rh sensitisation/ABO incompatibility—perinatal infection

• Antenatal or perinatal depression/psychosis

• Other

Medical

Mental health

• Depression, eating disorder, other

Family health

• Maternal—diabetes, hypertension/preeclampsia, multiple pregnancy, asthma, intellectual disability, haemoglobinopathy, allergies, other

• Congenital abnormalities (maternal and/or paternal)—chromosomal, limb deformity, metabolic, neural tube defect, cardiac defect, cleft palate, dislocated hip(s), severe infant morbidity, SIDS/SUDI, other

ABO = ABO blood group; APH = antepartum haemorrhage; Hb = haemoglobin level; HIV = human immunodeficiency virus; IUGR = intrauterine growth restriction; MRSA = methicillin-resistant Staphylococcus aureus; Rh = rhesus factor; SGA = small for gestational age; SIDS = sudden infant death syndrome; STI = sexually transmitted infection; SUDI = sudden unexpected death in infancy; TB = tuberculosis.

Identifying the present

As part of the booking visit, the midwife also undertakes a ‘current health review’ (see Box 22.3) and an initial examination, in order to establish baseline information and facilitate the process of planning the care. All the issues identified in the ‘current health review’, and those raised in the aforementioned historical health review, have the potential to influence the process or outcome of pregnancy, although some are more significant than others. They should provide the midwife with cues as to the nature and detail of any physical examination that may be required.

Box 22.3 Current health review

Physical

Emotional

• General health, psychological wellbeing

• Feelings about pregnancy and having a baby

• Planned/unplanned and welcome/unwelcome pregnancy

Social

• Autonomy, support, resources, employment, community ‘belonging’ or isolated

• Is there a current relationship—partner, husband? Is it stable and supportive?

Cultural

• Identity, integration/isolation, support, resources, needs

• Safety issues

Spiritual

• Any spiritual and/or religious beliefs that may influence needs, choices or care options

Current pregnancy: establish EDD

• LMP (sure/unsure), known conception date

• EDD (consider 283-day option)

• Positive pregnancy test

• Menstrual cycle—regular/irregular/frequency, contraception, last cycle and menstruation normal (Y/N, details)

BMI = body mass index; BP = blood pressure; EDD = estimated due date; LMP = last menstrual period; MSU = midstream urine sample; STI = sexually transmitted infection.

Currently, there is no consensus as to the detail, make-up and content of a ‘routine’ initial physical examination of a well pregnant woman. Kean and Chan (2007) state that ‘there is very little to be gained from a full formal physical examination’ (p 70). They suggest that ‘routine auscultation for maternal heart sounds in asymptomatic women with no cardiac history is unnecessary’, and that neither formal breast examination nor routine pelvic examination is appropriate (Kean & Chan 2007). The NICE (2008) guidelines do not address the issue of cardiac examination, but support the recommendation against routine breast and pelvic assessments. In contrast, Frye (1998) recommends a full medical examination including the above checks and details such as assessment of lymph nodes, reflexes, mouth, eyes and lungs, in addition to the ‘vital signs’. It is debatable whether such an examination is indicated, or within the scope of midwifery practice. Certainly, midwives generally work with well women, and should have sound knowledge of normal anatomy, physiology and organ and hormone function as well as being able to recognise signs of dysfunction, but a routine full examination may be both inappropriate and outside the midwifery scope of practice. To date, there is limited evidence available which addresses this issue to any significant degree.

It is important to distinguish between something that is offered routinely, and that which is offered in response to risk markers. For example, offering vaginal swabs as a screening test routinely is not currently recommended, but for a woman with a history of unsafe sex practice and/or Chlamydia infection, screening may well be indicated. In such cases it is appropriate to discuss the option of carrying out a diagnostic test to identify whether there is a current infection, along with issues of self-care, and the potential risks from such an infection to the woman’s health and wellbeing and that of her baby.