Antenatal and Postnatal Care

The Aim of Antenatal Care

The aim of antenatal care is to maximise the chance of a positive outcome from a pregnancy: a healthy mother and a healthy baby or babies. This will involve regular contact between a pregnant woman and health care professionals.

The aims of antenatal care are to:

Optimise maternal and fetal health
Offer women maternal and fetal screening
Make medical and social interventions where indicated
Improve women’s experience of pregnancy and birth
Prepare women for motherhood

Antenatal care may be one of the few occasions that a woman has regular contact with health care providers. Thus, it is an ideal opportunity to promote positive health behaviours and provide education and guidance.

Models of Antenatal Care

Models of antenatal care, and maternity care more generally, vary widely across the world ( Fig. 23.1 ). The model of antenatal care includes how often the care is given, who provides the care, and where the care is located. It is determined by a range of factors, including patient history and preference, resource level, and organisation of care.

Fig. 23.1, The dual purpose of antenatal care.

In middle- and high-income countries, the pattern of antenatal appointments is generally around 10 appointments for a woman in her first pregnancy and seven for a woman in a subsequent pregnancy. In low-income countries, the number of contacts is often much lower, though the World Health Organization (WHO) recommends a minimum of eight antenatal contacts.

The providers of antenatal care also vary considerably between countries and within countries. Antenatal care may be provided by midwives, general practitioners, and obstetricians. Healthy women without any significant risk factors or obstetric problems may receive all of their care from midwives. Women with risk factors, health problems, obstetric problems, or poor obstetric history will also receive some of their antenatal care from obstetricians. Continuity of carer during the antenatal period is associated with improved obstetric outcomes and increased maternal satisfaction.

The First Trimester

Ideally, the first contact between a health care professional and a pregnant woman occurs soon after the confirmation of pregnancy. We aim for women to have their first ‘booking’ appointment by 10 weeks’ gestation.

The aims of this booking appointment are to:

Identify risks
Screen for abnormalities or illness
Provide key health-promotion messages
Develop a rapport and encourage future attendance by ensuring that the woman has a positive first experience of maternity care.

At the booking appointment, the gestation of the pregnancy should be determined through establishment of the first day of the last menstrual period and abdominal examination. Initial observations of the mother will assist with care planning and identification of any later deterioration.

Several risk factors increase the probability that problems or complications may emerge for the mother or fetus in pregnancy, during labour and childbirth, or postnatally. Being under 18 or over 40 years of age increases the risk of developing some problems during pregnancy, as does having had more than six previous births or having a first pregnancy.

Women may have underlying health conditions for which they take medication. The health care professional should identify what medication is currently being taken (both prescription and ‘over the counter’ medicines) and assess the risks and benefits of continuing the medication in pregnancy. Some women will need to keep taking their regular prescribed medications; they should be given accurate advice regarding this. Risk factors should be recorded and considered when planning care ( Table 23.1 ).

Table 23.1

Risk Factors to Be Identified at First Appointment Through Discussion With Mother and Reference to Previous Medical or Obstetric Notes

Personal History and Current Health	Family History	Obstetric History Previous Pregnancies	Current Pregnancy
History of subfertility and fertility treatment	Pregnancy related—first-degree relative with a congenital abnormality or genetic abnormality, pre-eclampsia, venous thrombosis	Miscarriage at > 14 weeks, stillbirth or neonatal death	Hyperemesis
Medical condition, including diabetes, thyroid problems, epilepsy, asthma, heart disease, hypertension, renal disease, cancer	Medical conditions—diabetes, heart disease, inherited conditions, e.g., sickle cell anaemia, cystic fibrosis	Recurrent miscarriage (two consecutive first-trimester losses)	Vaginal bleeding
Surgical history—gynaecological procedures, treatment to the cervix, breast surgery, abdominal surgery	Mental health—first-degree relative with postpartum psychosis, schizophrenia, bipolar disorder, severe postnatal depression or depression	Premature birth or small-for-gestational-age infant	Abdominal pain
Raised body mass index (BMI) or very low BMI		Pregnancy-related hypertension, gestational diabetes, rhesus isoimmunisation antepartum haemorrhage	Findings from pregnancy ultrasound
Mental health—bipolar disorder, postpartum psychosis, schizophrenia, depression, postnatal depression, anxiety disorders, eating disorders		Induction of labour—indication
Lifestyle—alcohol, smoking, non-prescription and prescription drug use		Operative birth (caesarean section or instrumental vaginal delivery), shoulder dystocia, breech birth
Social difficulties—domestic abuse, financial difficulties, previous child-protection concerns		Postpartum haemorrhage, retained placenta, obstetric anal sphincter injury

If risk factors are identified, the health care professional should follow local referral pathways to ensure that women receive the appropriate surveillance, treatment, advice, or support to reduce the impact of the risks identified. Some interventions, such as aspirin to reduce the risk of pre-eclampsia or fetal growth restriction (FGR) in high-risk women, should be commenced in the first trimester.

Some family history and previous personal history risks will require additional screening appointments and multidisciplinary care planning. A personal history of postpartum psychosis has a recurrence risk of 1 in 2 to 4 (background risk of 1 in 500), and a family history of inherited blood disorders will require relevant counselling and screening. Medical conditions such as diabetes, thyroid conditions, and epilepsy will require multidisciplinary care planning and monitoring throughout the pregnancy (see Chapter 24). Previous obstetric complications or interventions, such as a caesarean section or shoulder dystocia, require discussion of choices relating to birth.

Identifying lifestyle risks may prompt referral for smoking cessation support or dietetic support to promote healthy eating. Identifying mental health risks, such as a personal history of bipolar disorder, will require liaison with mental health services to ensure that a coordinated plan of care is in place during pregnancy and immediately after birth. Social difficulties will require a liaison with local social care or voluntary sector organisations.

At the first antenatal appointment, the health care professional will undertake a general physical examination, including calculation of the woman’s body mass index (BMI), blood pressure measurement, and heart rate. In areas with a high incidence of cardiac and respiratory conditions, auscultation of heart and lung sounds is recommended. An abdominal examination will be undertaken to identify the uterine size and any abnormal masses or surgical scars.

Urinalysis should be undertaken for the presence of protein and glucose; proteinuria prompts testing for urinary tract infection, persistent glycosuria prompts testing for diabetes. Cervical screening is not routinely required but can be safely done in pregnancy, and contact with health professionals in pregnancy can provide an opportune time to address overdue cervical screening.

Further screening will differ between different countries, depending on local disease patterns and resources, but often includes:

Full blood count to screen for maternal anaemia and thrombocytopenia
Blood group to determine the ABO and rhesus status of the mother and to identify any red cell antibodies
Rubella status to identify those mothers who are not immune. This has been discontinued as part of routine care in the United Kingdom since 2016 due to the high population coverage provided by the measles-mumps-rubella vaccine but remains part of routine care in Australasia.
Haemoglobin (Hb) electrophoresis to screen for conditions such as thalassaemia and sickle cell anaemia
Hepatitis B status. Women who are identified as positive for hepatitis B can have medication in the third trimester to reduce the risk of vertical transmission if they have a high viral load. The baby should also receive immunoglobulin and vaccination at birth.
Syphilis. Syphilis rates are unfortunately increasing. Untreated syphilis in pregnancy is associated with miscarriage, stillbirth, and congenital syphilis (see pp. 204, 306).
Human immunodeficiency virus (see p. 206).
Hepatitis C screening should be considered for women at risk, such as intravenous drug users.
Swabs for chlamydia should be offered to those at risk, such as women aged under 25 years.
HbA1c can be used to assess for underlying type 2 diabetes. This is not routine in the United Kingdom but is in Australasia.

A clear process should be in place and shared with the woman about how and when she will receive test results following this first appointment.

Many women experience some discomfort or symptoms that may cause them to be concerned during the early stages of pregnancy. These include nausea and vomiting (‘morning sickness’), some lower abdominal discomfort, frequency of micturition, vaginal ‘spotting’ (small amounts of bleeding per vagina), and breast tingling or discomfort. The health care professional should ask women about symptoms to identify when normal and transient discomforts appear to be more serious.

The booking appointment should include discussion about a woman’s options for screening for chromosomal and structural fetal anomalies. Screening approaches vary in different countries. Screening for Down syndrome (T21) and/or Edwards (T18) and Patau syndrome (T13) usually includes a nuchal translucency scan between 11 and 14 weeks, combined with maternal blood tests for pregnancy-associated plasma protein A (PAPP-A) and human chorionic gonadotrophin (hCG) to provide a combined test. The nuchal translucency scan also allows for confirmation of pregnancy dating and fetal number and an early assessment of fetal anatomy. Women who miss this test can have a ‘quadruple test’ between 15 and 20 weeks’ gestation, when blood is tested for alpha-fetoprotein, inhibin A, estradiol, and hCG to calculate the chance of the baby being affected by T21 (but not T13). Women should be advised that initial screening will not provide them with a conclusive diagnostic answer about the presence or absence of an abnormality but will present them with information on the risk of abnormality, enabling them to make a further decision about diagnostic testing (chorionic villus sampling or amniocentesis). Non-invasive prenatal screening tests (NIPTs) can be performed from 10 weeks’ gestation onwards. A sample of maternal blood is taken, and the cell-free fetal DNA is extracted and analysed. Some of this comes from the baby’s placenta, which allows testing for trisomy 21, 13, and 18 and fetal sex. NIPT has a much higher sensitivity and specificity than combined testing but remains solely a screening test; a positive result should be confirmed by diagnostic testing. Women may choose to use NIPTs as first-line testing or to proceed to NIPTs if the combined testing result is high risk (see Chapter 25).

Some women will choose not to undergo screening for fetal abnormality, as they would not terminate a pregnancy if an abnormality were found and feel they would not benefit from knowing about any conditions prior to the birth. Other women may choose to have screening, as they may wish to decide not to continue with a pregnancy if an abnormality is found, or they may wish to have time to prepare for a baby with additional needs. The morphology scan or fetal anatomy scan performed between 18 and 22 weeks allows for assessment for fetal anomalies and placental position.

For a significant proportion of women, pregnancy is the first time that they have regular contact with health services. It is important to make this contact as positive as possible to ensure that women feel motivated to return for regular appointments and are confident to seek help should problems arise.

All health care professionals should treat the woman with respect at this first appointment:

Introduce yourself by role and name.
Ask the woman what she prefers to be called, and call her by that name.
Ensure that the woman’s conversation with you is private and cannot be overheard by other women attending for care.
Provide enough time to complete the appointment adequately.
Explain the purpose of the appointment and the questions being posed.
Ensure that the woman is able to communicate effectively with the health care professional. Provide an interpreter when required. Ideally, this interpreter will not be a family member or friend.
Offer the woman evidence-based information to assist her in coming to an informed choice on care options or screening.
Ask for verbal consent before undertaking any physical examination or taking a blood sample.
Offer the woman and her partner (if present) the opportunity to ask any questions they have regarding the pregnancy, any problems, or the care planned.
Explain the plan of care for the remainder of her pregnancy and the importance of attending regularly for antenatal care to monitor her and the baby’s health and well-being.
Ensure that services are culturally appropriate.

When a woman is helped to feel relaxed and comfortable during this first appointment, she will be more likely to share concerns with her healthcare professional and to attend future appointments.

Motivational interviewing or brief intervention approaches can be helpful in exploring a woman’s readiness to make positive health behaviour changes, such as giving up smoking, drinking alcohol, or using illicit drugs; eating healthily; and being more physically active. The health care professional can best support women to make positive changes through providing clear information about the impact of particular behaviours on maternal and fetal health, while remaining non-judgemental in approach. Pregnancy is a time when women are making many changes in their lives; brief interventions, including advice and support, can have a big impact.

Smoking, alcohol, and illicit drug use

The health care professional should screen for alcohol intake, smoking, and use of illicit drugs during pregnancy.

Smoking in pregnancy is linked to miscarriage, premature birth, small-for-gestational-age babies, stillbirth, sudden unexpected death in infancy (SUDI), and increased hospital admissions in the first year of a baby’s life.

Alcohol, including ‘binge drinking’, is related to a spectrum of potential problems categorised as fetal alcohol spectrum disorder (FASD). It is estimated that as many as 1 in 100 babies are born with effects from alcohol. A safe level of alcohol use in pregnancy has not been determined, although the risk of FASD increases with increasing alcohol intake. The best advice is that ‘there is no known safe level of alcohol intake in pregnancy’, and women should avoid alcohol in pregnancy. FASD has a lifelong impact on the affected person, including learning and behavioural difficulties.

Illicit drugs (marijuana, opiates, cocaine, and methamphetamines) increase the risk of adverse pregnancy outcomes, although it is often difficult to separate outcomes from confounding factors such as cigarette smoking and socioeconomic deprivation. Marijuana use in pregnancy is associated with an increased risk of pre-term birth and poor neonatal outcomes. Pregnancy can provide an opportunity to start women on opioid replacement therapy to try to stop illicit drug use.

Diet

The health care professional can provide helpful information about a healthy diet during pregnancy, including eating plenty of fruit and vegetables, good food hygiene, and foods to avoid, such as unpasteurised milk. Vitamin and mineral supplements are a helpful addition to a balanced diet for pregnant women. The WHO recommends that all women take 400 μg folic acid supplements for the first 12 weeks of pregnancy to reduce the risk of neural tube defects (national guidance on the dose of folic acid may vary, e.g., in Australia 500 μg, in New Zealand 800 μg, and in the United States 600 μg). In the United Kingdom, 5 μg daily vitamin D supplements are also recommended for all pregnant women. Routine iodine supplementation is recommended in Australasia. Women should be advised to avoid vitamin A supplements, as they may be teratogenic.

Physical activity and exercise

It is beneficial for women to be physically active during pregnancy. Advice about physical activity in pregnancy is the same as for all adults, that is, five periods of moderate physical activity for around 30 minutes each week. Moderate physical activity includes walking, swimming, gardening, and yoga. Physical activity and exercise are helpful in maintaining and improving physical and mental health in pregnancy and may help to relieve some of the discomforts of pregnancy. Exercise that risks abdominal trauma (e.g., contact tackle sports) should be avoided after the first trimester, and scuba diving is contraindicated in pregnancy.

Social and environmental factors

Health care professionals should ensure that, on at least one occasion during the pregnancy, they have some time alone with a woman in order to enquire about the woman’s home situation and whether she is experiencing domestic violence or abuse. Violence against women in their own homes can begin or escalate in pregnancy. If a woman discloses violence or abuse, the health care professional should offer the woman support and appropriate onwards referral.

Health care professionals have a responsibility to consider the welfare of the woman, her new baby, and any other children in the family by assessing for issues of concern in the woman’s life. These issues include domestic abuse, substance misuse, involvement with the judicial system, homelessness, and poverty. Health care professionals should talk to the woman about the need to make referral for social support through social services and/or voluntary sector organisations. Health care professionals should familiarise themselves with their local safeguarding and child-protection procedures.

Pregnant women who are recent migrants, asylum speakers or refugees, or who have difficulty reading or speaking the local language may face additional challenges in making full use of antenatal care services. Health care professionals should help support these women to obtain appropriate pregnancy care by using interpreters when required, using a variety of means to communicate with women, and educating women about antenatal care services and how to use them.

Vaccinations

It is recommended that pregnant women receive a pertussis booster each pregnancy from the second trimester onwards to provide some protection to the baby until it can receive its vaccinations. Influenza vaccine is recommended in at any gestation of pregnancy, given the association of influenza with severe maternal illness and perinatal complications. Tetanus immunisation is recommended, if the woman has not already received a full course, to reduce the risk of neonatal tetanus.

The Second Trimester (12–26 Weeks)

Antenatal care during the second trimester includes follow-up on results from initial blood tests, fetal anomaly screening at 18 to 22 weeks, and instigating any treatment or further surveillance indicated by these results.

At each antenatal appointment throughout the second trimester, the following should be assessed and recorded:

Maternal blood pressure
Maternal urinalysis
Enquiry about any pain or vaginal loss
Auscultation of the fetal heart from 18 weeks.

The health care professional should enquire about the woman’s well-being, both physical and emotional, at each appointment. Many women experience symptoms that cause them discomfort or concern during pregnancy. Through discussing the impact of symptoms on a woman’s life, the health care professional can identify when problems are of concern and require further investigation and possible follow-up ( Table 23.2 ).

Table 23.2

Common Problems or ‘Minor Disorders’ of Pregnancy

Condition	Advice, Possible Treatment
Nausea and vomiting	Investigate severity through history-taking. If more than occasional, monitor weight, dehydration (ketones on urinalysis), consider hospitalisation; exclude urinary infection as cause; advise woman to eat little and often. Antiemetics can be safely prescribed.
Heartburn	Antacids; monitoring of diet to identify which foods worsen or improve symptoms; advise woman to eat little and often. If persistent and not relieved by common treatments, consider treatment with H ₂ antagonists.
Haemorrhoids	Over-the-counter treatments; woman needs to avoid constipation through remaining well hydrated and eating plenty of fruit and vegetables.
Constipation	Over-the-counter treatments; woman needs to avoid constipation through remaining well hydrated and eating plenty of fruit and vegetables, and increase fibre in diet.
Pelvic girdle pain, sciatica, back pain	Avoid over-abduction of hips; refer for physiotherapy—use of prescribed exercises to relieve pain, improve mobility, and strengthen muscles. Maternity belts can be helpful. In more severe cases, walking aids may be required.
Anaemia	Usually iron deficiency; thus, prescribe an iron supplement; improve intake of iron-rich foods; and monitor improvement.
Carpal tunnel syndrome	Monitor severity; exclude pre-eclampsia; refer for physiotherapy; wrist splints may be helpful.
Bleeding gums	Gingivitis or gum disease is more common due to hormonal changes in pregnancy. Careful oral hygiene and dental check-up recommended.
Fatigue	Fatigue is common in pregnancy, particularly the first trimester. Screen for anaemia; encourage physical activity to improve sleep quality.
Itching	Itching is quite common in pregnancy due to hormonal changes and stretching of the skin. However, severe itching, particularly after 30 weeks, can indicate obstetric cholestasis, which requires confirmation by testing of liver function and bile acid levels.
Rashes	Polymorphic eruption of pregnancy (1: 240 pregnancies); presents with abdominal urticaria and papules in striae with periumbilical area sparing, sometimes extends to the proximal limbs. Treat with antihistamines and topical steroids. It is more common in nulliparous women. Pemphigoid gestationis (1: 10,000 pregnancies); pruritic erythematous papules, plaques, and wheals spreading from the periumbilical area to the breasts, thighs and palms, associated with fetal compromise. Treat with antihistamines, topical steroids, and systemic steroids.
Vaginal discharge	A heavier discharge is normal during pregnancy. However, if the discharge is malodorous or accompanied by itching, a vaginal swab for culture is appropriate. In later pregnancy, ruptured membranes should be excluded (see Chapter 44).

Table 23.3

Care in the First Hours After Vaginal Birth

Neonate	Mother
Assessment of condition (represented by the Apgar score) at 1, 5, and 10 minutes—resuscitation only if indicated	Observation of vaginal blood loss, palpation of uterine fundus to identify if contracted
‘Skin-to-skin’ contact	Examine for perineal, labial and vaginal trauma, with repair as required. Offer analgesia.
Clamp and cut the umbilical cord—1–3 minutes after birth, unless the baby requires resuscitation	Support mother to hold baby skin-to-skin and, when she wishes, offer the breast to the baby
Measurement and recording of birth weight, length, head circumference, temperature	Observations—general well-being, colour, respirations, pulse, blood pressure, temperature
Initial physical examination of the neonate to identify any abnormalities—this should include examination of the head and facial features, the palate, limbs, digits, spine, and external genitalia	Offer something to eat and drink
A record should be made of the neonate’s first micturition and first feed	A record should be made of the mother’s first micturition after the birth
Discussion with parents about administration of vitamin K and administer with consent	Categorisation of the mother’s risk of venous thrombosis and commencement of prophylactic measures as appropriate

The Third Trimester (26 Weeks–Term)

At each antenatal contact, women should continue to have their blood pressure and urinalysis checked and clearly recorded in her maternity records. The following should also be assessed.

Abdominal examination

This examination will include inspection, palpation, and auscultation of the fetal heart using a hand-held Doppler device (or, occasionally, a Pinard stethoscope). If the fetal heart cannot be heard in this way, an ultrasound scan should be undertaken to assess fetal well-being.

Presentation

Examination and palpation of the uterus will identify the presentation, position, and descent of the fetus into the pelvis. Further information about malpresentations can be found in Chapter 34, pp 408.

Evaluation of fetal growth

At each appointment from 24 weeks onwards, the health care professional should measure from the symphysis pubis to the fundus of the uterus and plot the measurement (symphysis-fundal height [SFH]) on a growth chart. Customised charts such as Gestation-Related Optimal Growth (GROW) charts take into account a woman’s height, weight, ethnicity, and parity to calculate a baby’s growth potential. When the SFH measurement falls outside the normal range or is static over a few weeks, an ultrasound examination should be offered (see Chapter 27).

Enquiry about fetal movements

Each woman should be encouraged at each appointment to become familiar with the individual pattern of her baby’s movements. Movements will generally increase in frequency and strength until 32 weeks. Then, movements are likely to remain relatively stable until the birth. There should not be a reduction in movements closer to the birth, though the size of the movements may change. Women should be advised that the baby’s movements are a sign of the baby’s well-being. If they become aware of any reduction in the baby’s normal pattern of movements, they should lie down for an hour to rest and focus on the baby’s movements. If the movements continue to be reduced, they should seek advice from a health care professional on that day. Reduced fetal movement can be an indicator of fetal hypoxia and is a risk factor for intrauterine death.

A woman’s description of reduced fetal movements is important and should be responded to by a face-to-face consultation with fetal heart rate monitoring by cardiotocography (CTG) and the selective use of ultrasound.

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