Clinical Practice Guidelines Antenatal care - Module I

6.3 Planning antenatal visits

Page last updated: 02 April 2013

The needs of each woman should be assessed at the first appointment, reassessed at each visit, and be guided by the woman’s needs if and as they change. The environment in which visits take place should facilitate discussion of sensitive issues.

Planning for antenatal care allows assessments and tests to be conducted at the appropriate stage of pregnancy. At an early contact, explanation should be given of :

  • assessments and tests that are offered to all women;
  • any additional assessments that are recommended, the reasons why these may be appropriate for that woman, whether referral is required and when the assessment should occur; and
  • any continuing assessments that may be required or recommended during the pregnancy.
At this time, the woman’s overall health and preparation for birth and parenting and care of the newborn should also be assessed. Focused antenatal visits should include time for health professionals and women to talk about important issues related to health during pregnancy, including:
  • the importance of good nutrition to the health of the mother and baby;
  • the risks of using tobacco, alcohol, prescription and over-the-counter medicines and illicit drugs in pregnancy;
  • the risks and benefits of continuing existing medicines (eg antidepressants, hypertensives);
  • the risks associated with sexually transmitted and other infections in pregnancy;
  • other social and lifestyle factors that may affect the pregnancy;
  • the impact of work, physical activity and travel on pregnancy outcomes;
  • the danger signs of complications during pregnancy; and
  • preparation for the birth and early parenthood, including breastfeeding.
Practice point
a. Antenatal care should be woman-focused, with each antenatal visit structured around specific content based on the woman’s needs. Longer visits are needed early in pregnancy to allow comprehensive assessment, discussion and support. Assessments and tests should be incorporated into visits in a way that minimises inconvenience to the woman.

6.3.1 Content of antenatal visits

First antenatal visit/booking appointment

The first contact with a woman in the antenatal period may be when she attends primary care to confirm the pregnancy. Women will either start antenatal care at that point or be referred to a maternity care provider or service, for example, the local hospital, midwife, obstetrician, GP or Aboriginal health service. Women intending to give birth in hospital will attend a booking visit — this may be their first visit at the hospital if they are receiving care through this service or later in pregnancy if they are receiving care through a private provider.

The first antenatal visit should be longer than most later visits because of the large volume of information needed in early pregnancy. On occasion, two or more visits may be required to ensure there is sufficient time to cover “first visit” activities, particularly for women experiencing pregnancy for the first time. However, these extra visits should not be counted when planning the schedule for subsequent antenatal visits.

The need to discuss the many assessments and screening tests that are offered to women in the first trimester contributes to the length of the first visit. It is important to explain that no assessment or screening test is compulsory and that women have the right to make informed decisions. Considerations in discussing specific tests and available resources to assist with explanation are included in Chapter 8.

Additional time may be required for the first antenatal visit for women who have:
  • limited experience of the health system or a limited understanding of health care procedures — clear explanation of the reasons for antenatal visits, medical procedures and the use of technology is needed;
  • difficulties communicating in English — accredited interpreters should be involved and time for interpretation taken into consideration;
  • past experiences that affect their trust in authorities or health professionals — reassurance and explanation of the care being offered and collaboration with other services may be required to build necessary confidence and trust; or
  • other conditions that usually require additional care (see Table 6.2).

Table 6.1: Content of first antenatal visit

Woman-centred care

  • Seek women’s thoughts, views and opinions
  • Ask open-ended questions and provide an opportunity to discuss issues and ask questions
  • Offer verbal information supported by written or other appropriate form of information (on topics such as diet and lifestyle, available pregnancy care services, maternity benefits, screening tests, breastfeeding)
  • Discuss involvement of the woman’s partner/family in antenatal care

General assessment

  • Undertake a comprehensive history including:
    1. current pregnancy (planned, unplanned, woman wishes to proceed with/terminate pregnancy)
    2. medical (past history, medicines, family history, cervical smears, immunisation)
    3. obstetric (previous experience of pregnancy and birth)
    4. smoking, nutrition, alcohol, physical activity and drug use
    5. expectations, partner/family involvement, cultural and spiritual issues, concerns, knowledge, pregnancy, birth, breastfeeding and infant feeding options
  • Clinical assessment (see Chapter 8):
    1. discuss conception and date of last menstrual period and offer ultrasound scan for gestational age assessment to be carried out between 8 and 14 weeks of pregnancy
    2. measure height and weight and calculate body mass index
    3. measure blood pressure
    4. test for proteinuria
    5. ask questions about previous mental health disorders and psychosocial factors that affect mental health
    6. administer the Edinburgh Postnatal Depression Scale at this visit or as early as practical in pregnancy
  • Screening:
    1. check blood group and antibodies, full blood count and haemoglobin
    2. offer testing for HIV, hepatitis B, rubella non-immunity, syphilis and asymptomatic bacteriuria
    3. offer testing for hepatitis C to women with identified risk factors
    4. offer women younger than 25 years chlamydia testing — in areas with a high prevalence of sexually transmitted infections, consider offering chlamydia and gonorrhoea testing to all pregnant women
    5. consider offering testing for vitamin D deficiency
    6. offer screening for chromosomal abnormalities to be carried out between 11 and 14 weeks of pregnancy

Assessment

  • Estimated date of birth/gestational age
  • Current problems
  • Risk factors
  • Need for referral
  • Need for further investigation/ treatment/ preventive care

Actions

  • Referral
  • Further investigation
  • General advice (also for the partner/family) — pregnancy symptoms, supplements, smoking, nutrition, alcohol, physical activity, drug use, dental visits
  • Advice on options for antenatal care and place of birth or on access to counselling and termination where this is permitted under jurisdictional legislation
  • Specific preventive interventions — folate, iodine, immunisations, cervical smear, others as needed (eg iron supplement)
* Note that testing for diabetes is not considered in these Guidelines as the evidence is being reviewed and will be discussed in Module II.

The Guidelines include recommendations on baseline clinical care for all pregnant women but do not include information on the additional care that some women will require. Pregnant women with the conditions listed in Table 6.2 usually require care additional to that detailed in these Guidelines. Some resources that may assist in providing appropriate care are listed in Section 6.5.

Table 6.2: Women who may require additional care

Existing conditions

  • Cardiovascular disease (eg hypertension, rheumatic heart disease)
  • Other conditions (eg kidney disease, diabetes; thyroid, haematological or autoimmune disorders; epilepsy, malignancy; severe asthma; HIV, hepatitis B or hepatitis C infection)
  • Psychiatric disorders
  • Obesity or underweight
  • Female genital mutilation

Lifestyle considerations

  • History of alcohol misuse
  • Use of recreational drugs such as heroin, cocaine (including crack cocaine), ecstasy and cannabis

Mental health and psychosocial factors

  • Psychosocial issues/ mental health problems
  • Developmental delay or other disabilities
  • Vulnerability or lack of social support

Experiences in previous pregnancies

  • Recurrent miscarriage
  • Preterm birth
  • Pre-eclampsia or eclampsia
  • Rhesus isoimmunisation or other significant blood group antibodies
  • Uterine surgery (eg caesarean section, myomectomy or cone biopsy)
  • Antenatal or postpartum haemorrhage
  • Puerperal psychosis
  • Four or more previous births
  • A stillbirth or neonatal death
  • Small or large-for-gestational-age baby
  • Baby with a congenital abnormality (structural or chromosomal)
Source: Adapted from NICE (2008).

Subsequent antenatal visits

Determining the pattern of visits and the activities that are undertaken at each visit requires a degree of flexibility. Care should be collaboratively planned with the woman based on the needs identified through assessments. Planning should take also into account the involvement of the woman‘s partner/family.

At all visits, opportunities should be provided for the woman to share her expectations and experiences as well as discuss any issues and/or concerns that may have arisen since her last visit. Women should also be offered information on aspects of health in pregnancy and early parenthood (eg nutrition, alcohol, smoking, breastfeeding), supported by antenatal education opportunities. Later in pregnancy, it may be beneficial to promote positive body image and confidence in the woman’s ability to labour and give birth. The woman’s needs should dictate the type of information and support provided (eg while many women will benefit from written information, other forms of information such as audio or video are sometimes more suitable). The type of issues and questions discussed should also be directed by the woman.

Further information on the schedule and content of the rest of the antenatal visits will be included in Module II of these Guidelines.