Antenatal visits

Each antenatal visit should be structured around specific content that is based on the woman’s needs. Incorporating assessments and tests into visits minimises inconvenience to the woman.

While antenatal visits are well established as a means of improving perinatal outcomes, the number and timing of visits has been less studied NICE 2008. Systematic reviews and observational studies tend to show an association between number of antenatal visits and/or gestational age at first antenatal visit and pregnancy outcomes (Dowswell et al 2015), although there are many differences in sociodemographic and risk profiles of women attending for antenatal care that may contribute to these findings (Hueston et al 2003).

8.1 Background

Almost all women (99.9%) who gave birth in Australia in 2014 had at least one antenatal visit AIHW 2016:

• 95% had five or more visits
• 87% had seven or more visits
• 57% had ten or more visits (excludes data from Victoria).

Nationally, in 2014 AIHW 2016:

• 43% of women attended at least one antenatal visit in the first 10 weeks of pregnancy
• 62% of women attended in the first trimester (less than 14 weeks)
• around one in eight women (12%) did not begin antenatal care until after 20 weeks’ gestation.

Women living in the lowest socioeconomic status (SES) areas began antenatal care later in pregnancy; just over half (55%) of women living in the lowest SES areas attended antenatal care in the first trimester compared with 68% in the highest SES areas in 2014 AIHW 2016.

The proportion of women attending five or more antenatal visits varied slightly by remoteness and socioeconomic disadvantage (data exclude very preterm births and data from Victoria) AIHW 2016:

• 96% of women living in major cities compared with 90% in very remote areas
• 96% of women living in the highest SES areas compared with 93% in the lowest SES areas.

Indigenous women were less likely to attend either an antenatal visit in the first trimester (53% compared with 60% of non-Indigenous women) or to attend five or more visits (86% compared with 95% of non-Indigenous women) (age-standardised) AIHW 2016.

8.2 Number and timing of antenatal visits

A Cochrane review (Dowswell et al 2015), which included studies in high-, middle- and low-income countries, found no strong evidence of differences in the number of preterm births or low birth weight babies between groups receiving a reduced number of antenatal visits (eight visits in high-income countries and fewer than five visits in low-income countries) compared with standard care. However, there was some evidence that in low- and middle-income countries perinatal mortality may be increased with reduced visits. The number of inductions of labour and caesarean sections were similar in women receiving reduced visits compared with standard care.

Evidence concerning women’s preferences about the number of antenatal visits suggests that:

• for some women, the gap between visits was perceived as too long when the number of visits was lower than that traditionally offered (Dowswell et al 2015)
• women who were satisfied with a reduced number of antenatal visits were more likely to have a caregiver who both listened and encouraged them to ask questions than women who were not satisfied with reduced schedules (Clemet et al 1996)
• women who were over 35 years of age, had previous pregnancies, were less educated or had more than two children preferred fewer appointments, whereas women who were less than 25 years of age, single or had a prior adverse pregnancy history indicated a preference for more appointments than the standard schedule (Hildingsson et al 2002).

8.2.1 Timing of initiation of antenatal care

The NICE guidelines suggest that the first antenatal visit occur before 10 weeks pregnancy due to the high information needs in early pregnancy. This also allows arrangements to be made for tests that are most effective early in the pregnancy (eg gestational age assessment, testing for chromosomal anomalies).

8.2.2 Economic considerations

The NICE guidelines found inconclusive evidence regarding the cost-effectiveness of a reduced number of antenatal visits. Most of the existing research in developed countries is based on women assessed as at low risk of poor perinatal outcomes at first contact. The available evidence found that:

• providing routine antenatal care through five compared with eight visits did not affect maternal and perinatal outcomes and therefore was more cost effective (Villar et al 2001)
• reduced costs associated with six or seven versus thirteen visits were offset by the greater number of babies requiring special or intensive care, although maternal satisfaction and psychological outcomes were poorer in women attending fewer visits (Henderson et al 2000)
• although the average number of antenatal visits was lower in France than in England and Wales in 1970–80, there was no difference in pregnancy outcomes, suggesting that fewer visits would be more cost effective if only these outcomes are considered (Kaminski et al 1988)
• there was no significant difference in the monetary value women placed on different providers of antenatal care (Ryan et al 1997).

8.3 Discussing the schedule of antenatal visits with women

The first or another early contact with a woman provides an opportunity to assess the appropriate number of visits for her pregnancy. Considerations include:

• any conditions that may affect the pregnancy or the woman’s health and social and emotional wellbeing
• whether this is the first or a subsequent pregnancy
• the woman’s preferences for how antenatal care is provided.

This contact should be used to provide women with much of the information they need in early pregnancy. This includes explanation and appropriate written or other form of information about the different types of maternity care available and what each option entails. Information on each option of care should include:

• who the primary carer or carers will be and how they will care for the woman (one-to-one, as part of a team etc)
• the likely number, timing and content of antenatal visits
• place of labour and birth
• postnatal care and support.

8.4 Content of the first antenatal visit

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 volume of information that needs to be exchanged in early pregnancy. If there is insufficient time in the first antenatal visit, another appointment can be arranged to cover “first visit” activities or these can be incorporated into care as the pregnancy progresses.

Women should be seen alone at least once during pregnancy, particularly during the first antenatal visit, as the presence of the woman’s partner may be a barrier to disclosure of domestic violence or other aspects of the woman’s personal history.

The need to discuss the many assessments and 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 test is compulsory and that women have the right to make informed decisions.

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 processes: clear explanation of the reasons for antenatal visits, the need for tests and screening and the use of technology is needed
• limited understanding of English: accredited interpreters should be involved and time for interpretation taken into consideration (see Chapter 4)
• hearing impairment: use of Auslan (Australian Sign Language) should be used to facilitate communication
• 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
• psychosocial circumstances that may mean they need more intensive psychosocial support (eg young women, women with vulnerabilities); or
• other conditions that usually require additional care (see 8.4.1 Women who may require additional care ).

8.4.1 Content of first antenatal visit

Woman-centred care

• Seek woman’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 and tests, breastfeeding)
• Discuss involvement of the woman’s partner/family in antenatal care, using gender neutral language until the gender of the partner is established
• Provide emotional support and empathy
• Discuss any costs that may be involved in a woman’s antenatal care

Undertake a comprehensive history

• Current pregnancy (planned, unplanned, wishes to proceed with or terminate the pregnancy)
• Medical (history, medicines, family history [high blood pressure, diabetes, genetic conditions], cervical smears, immunisation, breast surgery)
• Obstetric (previous experience of pregnancy and birth)
• Infant feeding experiences
• Nutrition and physical activity
• Smoking, alcohol and other substance misuse
• Expectations, partner/family involvement, cultural and spiritual issues, concerns, knowledge, pregnancy, birth, breastfeeding and infant feeding options
• Factors that may affect the pregnancy or birth (eg female genital mutilation/cutting)
• Psychosocial factors affecting the woman’s emotional health and wellbeing
• The woman’s support networks and information needs

Clinical assessment

• Discuss conception and date of last menstrual period and offer ultrasound scan for gestational age assessment (carried out between 8 and 14 weeks of pregnancy)
• Measure height and weight and calculate body mass index and provide advice on appropriate weight gain
• Measure blood pressure
• Test for proteinuria
• Delay auscultation of fetal heart until after 12 weeks gestation if using a Doppler and 28 weeks gestation if using Doppler or a Pinard stethoscope
• Assess risk of pre-eclampsia and advise women at risk that low-dose aspirin from early pregnancy may be helpful in its prevention
• Assess risk of preterm birth and provide advice on risk and protective factors
• Administer the EPDS at this visit or as early as practical in pregnancy
• Ask questions about psychosocial factors that affect mental health

Maternal health testing

• Check blood group and antibodies, full blood count and haemoglobin concentration and consider testing ferritin in areas where prevalence of iron-deficiency anaemia is high
• Assess risk of diabetes and offer testing to women with risk factors
• Recommend testing for HIV, hepatitis B, hepatitis C, rubella non-immunity, syphilis, and asymptomatic bacteriuria
• Offer testing for gonorrhoea to women with identified risk factors
• Offer chlamydia testing to all women who are younger than 25 years
• In areas with a high prevalence of sexually transmitted infections, consider offering chlamydia and gonorrhoea testing to all pregnant women
• Offer testing for trichomoniasis to women who have symptoms
• Offer cytomegalovirus testing to women who have frequent contact with large numbers of very young children
• Offer thyroid function testing to women who have symptoms or high risk of thyroid dysfunction
• Only offer testing for vitamin D deficiency if there is a specific indication
• Offer testing for chromosomal anomalies
• Offer cervical screening to women who have not had a screen in the recommended period
• Advise women about measures to avoid toxoplasmosis or cytomegalovirus infection

Assessment

• Estimated date of birth/gestational age
• Risk factors: physical, social, emotional
• Need for referral
• Need for further investigation/ treatment/ preventive care

Actions

• Advice on options for antenatal care and place of birth
• Referral if required
• Further investigation as required
• General advice (also for the partner/family): pregnancy symptoms, supplements, smoking, nutrition, alcohol, physical activity, substance use, dental visits
• If required, access to counselling and termination (where permitted under jurisdictional legislation)
• Preventive interventions: folate, iodine, others as needed (eg iron supplement)
• Specific vaccinations including influenza and pertussis^[11]

These Guidelines include recommendations on baseline clinical care for women with low-risk pregnancies but do not include information on the additional care that some women will require. Pregnant women with the conditions listed in 8.4.1 Women who may require additional care usually require care additional to that detailed in these Guidelines. Some resources that may assist in providing appropriate care are listed in Section 8.6.

8.4.2 Women who may require additional care

Existing conditions

• Overweight or underweight
• Cardiovascular disease (eg hypertension, rheumatic heart disease)
• Other conditions (eg kidney disease; type 1 or type 2 diabetes; thyroid, haematological or autoimmune disorders; epilepsy; malignancy; severe asthma; HIV, hepatitis B or hepatitis C infection)
• Mental health disorders
• Disability
• Female genital mutilation/cutting

Experiences in previous pregnancies

• Termination of pregnancy
• More than two miscarriages
• Preterm birth
• Pre-eclampsia or eclampsia
• Rhesus isoimmunisation or other significant blood group antibodies
• Uterine surgery (eg caesarean section)
• Antenatal or postpartum haemorrhage
• Postpartum psychosis
• Four or more previous births
• A stillbirth or neonatal death
• Gestational diabetes
• Small or large-for-gestational-age baby
• Baby with a congenital anomaly (structural or chromosomal)

Previous major surgery

• Cardiac (including correction of congenital anomalies)
• Gastrointestinal (eg bowel resection)
• Bariatric (gastric bypass, lap-banding)
• Gynaecological (eg myomectomy, cone biopsy, large loop excision of the transformation zone [LLETZ])

Lifestyle considerations

• History of alcohol misuse
• Use of recreational drugs such as marijuana, heroin, cocaine (including crack cocaine), amphetamines (eg ‘ice’) and ecstasy

Psychosocial factors

• Developmental delay or other disabilities
• Vulnerability or lack of social support
• Previous experience of violence or social dislocation

Source: Adapted from NICE (2008).

8.5 Planning for subsequent antenatal visits

Determining the pattern of visits and the activities that are undertaken at each visit requires flexibility. Care should be collaboratively planned with the woman based on the needs identified through assessments, with a focus on continuity of care wherever possible. Planning should also take into account the involvement of the woman’s partner/family. For women who start antenatal care late in pregnancy, arrangements will be needed to ‘catch up’ on information and assessments that are usually offered earlier in pregnancy. 

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, including psychosocial support and mental health issues. Women should also be offered information on aspects of health in pregnancy and early parenthood (eg nutrition, alcohol, smoking, symptom relief if conditions common in pregnancy are being experienced, breastfeeding, reducing the risk of sudden and unexpected death in infancy [SUDI]). A woman’s confidence in her ability to labour, give birth and look after her new baby should be supported throughout antenatal care and antenatal education should also support her in preparing for changes to her life and her relationship with her partner and understanding the physical and emotional needs of the baby. 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 woman should also direct the type of issues and questions discussed.

The list of additional specific activities at antenatal visits indicate appropriate stages of gestation for screening, tests and clinical assessments, although flexibility is needed. Different women will need different aspects of care at different times. If any assessments or tests identify a need for follow-up, additional visits may be required.

8.5.1 Additional specific activities at subsequent antenatal visits

16–19 weeks:

• Review, discuss and record the results of all tests undertaken
• Reassess planned pattern of care for the pregnancy and identify whether additional care or referral is needed
• Assess fetal growth
• Offer fetal anatomy scan to be carried out at 18–20 weeks gestation
• Offer women the opportunity to be weighed, encourage self-monitoring of weight gain and discuss weight change, diet and level of physical activity

20–27 weeks:

• Assess fetal growth
• Discuss fetal movements: timing, normal patterns etc
• Measure blood pressure
• Test for proteinuria in women who have clinical indications of pre-eclampsia (eg high blood pressure)
• Offer women the opportunity to be weighed, encourage self-monitoring of weight gain and discuss weight change, diet and level of physical activity
• Test for hyperglycaemia between 24 and 28 weeks gestation
• Repeat ferritin testing if levels were identified as low in the first trimester

28 weeks:

• Assess fetal growth
• Discuss fetal movements
• Test for anaemia, blood group and antibodies
• Recommend Anti-D to rhesus-negative non-isoimmunised women
• Measure blood pressure
• Test for proteinuria in women who have clinical indications of pre-eclampsia (eg high blood pressure)
• Offer women the opportunity to be weighed, encourage self-monitoring of weight gain and discuss weight change, diet and level of physical activity
• Test for hyperglycaemia if this has not already been tested
• Enquire about mental health and administer the EPDS

29–34 weeks:

• Assess fetal growth
• Discuss fetal movements
• Review, discuss and record the results of tests undertaken at 28 weeks
• Reassess planned pattern of care for the pregnancy and identify women who need additional care, arranging referral if required
• Give information, with an opportunity to discuss issues and ask questions on preparation for labour and birth, including the birth plan, recognising active labour and positively managing the pain of normal labour (this may need to take place earlier in remote areas)
• Discuss breastfeeding (eg skin-to-skin contact at birth, early feeding, rooming-in, attachment, exclusive breastfeeding, feeding on demand, partner support); discuss safe infant formula feeding if a woman chooses to formula feed
• Measure blood pressure
• Test for proteinuria in women who have clinical indications of pre-eclampsia (eg high blood pressure)
• Offer women the opportunity to be weighed, encourage self-monitoring of weight gain and discuss weight change, diet and level of physical activity
• Offer repeat ultrasound at 32 weeks to women whose placenta extended over the internal cervical os (the opening of the cervix into the vagina) in the 18–20 week scan
• Recommend a second dose of Anti-D to rhesus-negative non-isoimmunised women at 34 weeks

35–37 weeks:

• Assess fetal growth
• Discuss fetal movements
• Give information, including care of the new baby, reducing risk of sudden and unexpected death in infancy (SUDI), newborn screening tests and vitamin K prophylaxis, psychosocial support available in the postnatal period including maternal and child health services and psychosocial supports, with an opportunity to discuss issues and ask questions
• 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 a range of options, including external cephalic version for breech presentation
• Offer testing for Group B streptococcus if organisational policy is to routinely test all women
• Measure blood pressure
• Test for proteinuria in women who have clinical indications of or risk factors for pre-eclampsia (eg high blood pressure)
• Offer women the opportunity to be weighed, encourage self-monitoring of weight gain and discuss weight change, diet and level of physical activity

38–40 weeks:

• Assess fetal growth
• Give information, including normal length of pregnancy and onset of labour, with an opportunity to discuss any fears and worries and ask questions
• Discuss fetal movements, including the need for prompt contact with a health professional if there are any concerns about reduced or absent movements
• Measure blood pressure
• Test for proteinuria in women who have clinical indications of pre-eclampsia (eg high blood pressure)
• Offer women the opportunity to be weighed, encourage self-monitoring of weight gain and discuss weight change, diet and level of physical activity

Women who have not given birth by 41 weeks:

• Give information, including discussion about options for prolonged pregnancy (eg membrane sweeping), with an opportunity to discuss issues and ask questions
• Discuss fetal movements, including the need for prompt contact with a health professional if there are any concerns about reduced or absent movements
• Measure blood pressure
• Test for proteinuria in women who have clinical indications of pre-eclampsia (eg high blood pressure)
• Offer women the opportunity to be weighed, encourage self-monitoring of weight gain and discuss weight change, diet and level of physical activity

8.6 Resources

• AHMC (2010) National Maternity Services Plan.

• Bouverie Centre (2012) Guidelines for Healthcare Providers Working with Same-sex Parented Families. Melbourne: Bouverie Centre, LaTrobe University, Vic Health. 
• Remote Primary Health Care Manuals (2017). Antenatal Care. In: Women’s Business Manual (6th edition). Alice Springs, NT: Centre for Remote Health.

8.6.1 Nutrition and physical activity

• See Section 11

8.6.2 Prevention

• Australian Technical Advisory Group on Immunisation (2017 update) Australian Immunisation Handbook. 10th edition. Canberra: Department of Health.
• NHMRC (2005) Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities. Canberra: National Health and Medical Research Council.
• Safe sleeping resources.

8.6.3 Family violence

• See Section 29.3

8.6.4 Sexually transmitted infections

• ASHA (2016) Australian STI Management Guidelines for Use in Primary Care. Australasian Sexual Health Alliance. Accessed: 7 August 2018.
• NSW STI Programs Unit (2013) General Practice Resources. Sydney: NSW STI Programs Unit.
• Queensland Sexual Health Clinical Management Guidelines.