Antenatal Care Overview

Antenatal Care

• The antenatal period is the time between conception and birth.
• Antenatal care includes planned visits with a midwife or doctor to assess and improve the wellbeing of the mother and baby throughout pregnancy.
• Institutionalized routine antenatal care began less than 80 years ago, aiming to reduce maternal and perinatal mortality.

Reasons for Antenatal Care

• Three domains of contemporary antenatal care:
  • Providing clinical care and therapeutic practices
  • Providing relevant and timely information (physiological, biomedical, behavioural and sociocultural)
  • Providing support (social, cultural, emotional and psychological)

Positive Pregnancy Experience

• Maintaining physical and social normality.
• Maintaining a healthy pregnancy for mother and baby.
• Effective transition to positive labour and birth.
• Achieving positive motherhood (including maternal self esteem, competence, autonomy.

Providers of Antenatal Care

• GPs, hospital antenatal clinics (medical and midwifery) and obstetricians
• Midwives can provide independent antenatal and postnatal care in the community.

Antenatal care is still evolving:

• Some aspects of care are not evidence-based.
• Evidence-based guidelines have been developed.

COVID-19 and Pregnancy

• Pregnant women are a priority group to receive Pfizer or Moderna vaccines.
• Pregnant women with COVID-19 have a higher risk of severe illness compared to non-pregnant women of the same age.
• Increased risk of:
  • Hospitalization
  • Admission to an intensive care unit
  • Invasive ventilation.
• Increased risk of complications for the baby, including stillbirth and premature birth.
• Pregnant women should be offered the COVID-19 vaccine at any stage of pregnancy.

Booking Visit

• Assess for risk factors: physical, social and emotional.
• Consult and/or refer as necessary using guidelines for consultation and referral.
• Consider referral to other interprofessional colleagues like dietician, physiotherapist, psychologist etc.

Routine Antenatal Visits:

• All visits should provide woman-centred care.
• Discuss EDC and check blood group.
• Check in re woman’s expectations & experiences.
• Check any outstanding results.
• Ask about general health & wellbeing.

Assessments at Every Visit

• Blood pressure
• Leg oedema
• Abdominal examination – fundal height assessment
• Psychosocial assessment – domestic violence
• Encourage self monitoring of weight gain, diet and level of physical activity
• Smoking history

Antenatal Visit: 16 -19 weeks

• Offer fatal anatomy scan to be carried out at 18 and 20 weeks gestation.

Antenatal Visit: 20-27 weeks

• Test for hyperglycaemia (glucose tolerance test) between 24 and 28 weeks.
• Repeat ferritin testing if levels were low in first trimester.
• Discuss and assess fetal movements: normal patterns, timing etc.
• Test for proteinuria in women who have clinical indications of pre-eclampsia (e.g. high blood pressure).

Antenatal Visit: 28 weeks

• Test for anaemia, blood group and antibodies.
• Recommend Anti-D to rhesus negative non-isoimmunised women.
• Administer EPDS.

Antenatal Visit: 29-34 weeks

• Give information and opportunity to discuss issues and questions on preparation for labour and birth:
  • Birth plan
  • Recognising active labour
  • Positively managing the pain of normal labour
• Discuss breastfeeding including benefits and ways to encourage successful breastfeeding (e.g. skin to skin, rooming in etc.).
• Offer repeat ultrasound at 32 weeks to women whose placenta extended over the internal cervical os in the 18-20 week scan.
• Recommend a second dose of Anti-D to rhesus negative non-isoimmunised women at 34 weeks.

Antenatal Visit: 35 - 37 weeks

• Give information on:
  • Care of the new baby
  • SUID (Sudden and Unexpected Death in Infancy)
  • Newborn screening tests and vitamin K prophylaxis
  • Psychosocial support available in the postnatal period
• Assess fetal presentation by abdominal palpation from 36 weeks and confirm suspected malpresentation by ultrasound.
• For women whose babies are not a cephalic presentation, discuss options including external cephalic version for breech presentation.
• Offer testing for group B streptococcus if organizational policy is to routinely test all women.

Antenatal Visit: 40 weeks

• Routine visit.
• Make sure woman knows when to come in to hospital, where to go.
• From 40 weeks consider discussing natural induction of labour methods (evidence based!).
• Offer “stretch and sweep” at 40 weeks in primiparous women.

Antenatal Visit: 41+ weeks

• Discuss natural IOL methods.
• Discuss options for prolonged pregnancy, including local policy on induction of labour for postdates induction.
• Offer stretch and sweep in multiparous women at 41 weeks (and again in primiparous women).

Blood Pressure in Pregnancy

• How?*

• Appropriately sized cuff (use large cuff if upper arm circumference is >33cm).

• Use L arm consistently.

• Manual sphygmomanometer:

  • Systolic BP = the first sound heard (Korotkoff 1)
  • Diastolic = the disappearance of sounds completely (Korotkoff 5).
  • If no K5, K4 (muffling) is accepted.

• May need to repeat readings over several hours.

• Automated devices give similar mean blood pressure values to mercury sphygmomanometry, but there is wide intra-individual error.

• The accuracy of automated blood pressure monitors may be compromised in preeclamptic women.

• Only a few automated blood pressure monitors have been validated for use in normotensive or mildly hypertensive pregnant women.

• In women with preeclampsia, especially those with severe hypertension, the accuracy of some devices declines and cannot be recommended for use in preeclampsia.

• Why?*

• Hypertension can be exceptionally dangerous for the pregnant woman and her fetus.

• Hypertension is defined as systolic ≥ 140mmhg and/or diastolic ≥ 90mmhg.

• Severe – systolic ≥ 170mmhg and/or diastolic blood pressure ≥110mmhg.

• Rise from booking in BP maybe significant (≥30mmhg systolic +/- 15mmhg diastolic) but not supported by current evidence.

• Four classifications of hypertension during pregnancy:

  • Gestational hypertension (onset at 20 weeks gestation or more).
  • Preeclampsia.
  • Chronic hypertension.
  • Preeclampsia superimposed on chronic hypertension.

Gestational Diabetes

• Why?*

• Gestational diabetes is caused by insulin resistance that develops in pregnancy.

• Poorly controlled gestational diabetes can be dangerous for the woman and her fetus.

• How?*

• There is a lack of an agreed gold standard for diagnosis gestational diabetes.

• The pregnancy care guidelines recommend that testing for hyperglycaemia is offered to ALL women between 24 and 28 weeks gestation.

• Testing is usually done with a glucose tolerance test at around 26-28 weeks, alongside an FBE and antibody screen.

Group B Streptococcus

• Why?*

• Group B streptococcus (GBS) is a common bacterium that can live in the gi tract, vagina and urethra.

• GBS is transmitted to the baby in 1-2 per 1000 live births.

• Colonisation in the newborn can lead to serious infections (including late onset up to 3 months of age).

• Intravenous antibiotic treatment during labour can prevent early onset GBS infection in close to 90% of newborns of mothers colonized with the bacteria.

• How?*

• Some organisations offer routine screening of GBS at 35-36 weeks by conducting a vaginal +/- rectal swab (including rectal swab results in higher sensitivity than vaginal swab alone).

Oral Health Advice

• Why?*

• Pregnancy doesn’t cause dental problems but physiological changes make them more likely.

• Vomiting exposes teeth to acid.

• How?*

• Encourage dental check up early in pregnancy.

• Dental treatment can be safely provided during pregnancy if the dentist is informed of the pregnancy.

• To reduce the impact of vomiting on teeth:

  • Rinse mouth with bicarb soda solution after vomiting.
  • Avoid brushing teeth immediately after vomiting (effect of erosion increased by brushing an already demineralised tooth surface).

Physical Activity During Pregnancy

• Why?*

• Physical activity in pregnancy can:

  • Reduce back and pelvic pain
  • Decrease risk of pregnancy complications (pre-eclampsia and gestational hypertension)
  • Control weight gain
  • Reduce risk of anxiety and depression

• How?*

• Assess activity levels during each antenatal visit.

• Provide advice – explain the benefits of regular physical activity and appropriate types of activity.

• Provide information on local supports, group activities.

• Assist women to identify ways of being physically active that are appropriate to their cultural beliefs and practices.

Sexual Activity During Pregnancy

• Why?*

• Women and their partners may ask about the safety of sexual activity during pregnancy.

• How?*

• Discuss concerns, including a change in desire for sex as pregnancy progresses, and after the birth.

• There is little evidence of harm to low risk pregnancies.

This quiz explores the antenatal period, emphasizing the importance of antenatal care in ensuring the wellbeing of both mother and baby. It covers the reasons for antenatal care, the domains it encompasses, and the various providers involved in this essential process. Test your knowledge and understanding of antenatal care and its significance in maternal health.