16/03/2015

ANTENATAL CARE
ALLI S ON C U M M IN S

WHAT IS ANTENATAL CARE?

Feelings, clinical assessment, promoting best

care for mother and baby, even when views
differ.
Be responsible and supportive

Kind and compassionate, ask consent

partnership negotiated
information is shared
options are discussed
choices supported and made
normality and wellness in pregnancy promoted,
preg, not a medical condition.

ANTENATAL CARE
Aim is to monitor the progress of pregnancy in
order to support maternal health and normal fetal
development
Traditional patterns of antenatal care (14 visits)
that existed from 1929 did not necessarily detect
complications and women were not satisfied

infection control
antibiotics
big players in lowering mortality

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Antenatal care based on the medical model

began in the 1920s with an aim of reducing
maternal and perinatal mortality
Based on the notion that pregnancy is a state of pathology
rather than a normal physiological event for a woman

ANTENATAL CARE
In considering traditional methods of antenatal
care what are the important aspects in this care?
What do you think women want from antenatal
care?
What do you see as the limitations to the
traditional model of antenatal care?
What models of antenatal care are available?

Trust through continuity, to be heard

emotional support, they want to be
reassured that all her fears are normal
and common among pregnant women
privacy - Sexual abuse, history, dom
violence
answers to questions
be empowered by the midwife
limitations incl: availability and location
(access to services)

CONTEMPORARY ANTENATAL CARE

More recently, flexible approach caution as an individualistic
approach is needed as a reduction in visits can result in
women feeling dissatisfied related also to what is done in
visits, not only number
Contemporary antenatal care enables women to make
informed decisions based on her needs after discussion with
the health care provider

Information offered should be based on the best available

evidence and supported by written information where available
The womans decision and choices for pregnancy birth and
beyond may be a challenge to the health care provider

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APPROACHES TO CARE
Midwife led
Team
Caseload
Midwives clinic

GP led
Private obstetrician or private midwife
Shared care
Any combination:

GP
obstetrician
midwife
Specialist obstetricians

APPROACHES TO CARE

Continuity of care/carer
Antenatal groups
Collaborative practice
Complex social needs

continuity provides
less intervention, epidural, c-sect less likely
to occur
greater birth experience

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SUGGESTED SCHEDULE OF VISITS
Identify low versus high risk pregnancy according to
ACM/local guidelines throughout the pregnancy
Provide the woman with number timing and
content of antenatal care available models of
care
Appropriate format

Recommend the following antenatal visits schedule

depending on the womans needs:
Booking within10 weeks
Primips 10 visits
Multips uncomplicated pregnancy 7 visits

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GETTING TO KNOW THE WOMAN

BOOKING HISTORY

understanding

Usually recommended before 10 weeks longer visit

Beginning of care relationship
Process of information sharing
Woman focused, specific content around the
womans needs

Review the past, identify the present and plan the

future

CONTENT

Seek womans views/opinions

Planned/unplanned pregnancy choices
Involvement of partner
Offer verbal information (supported by written
information)

Diet
Exercise
Lifestyle
Pregnancy care services
Maternity benefits
Screening
Breastfeeding

diet - whole, fresh foods, follow food guidelines

supplements, iron, doesnt need to eat for two
cooked foods, no unpasteurised milk/ soft cheeses listeria can cause problems
exercise- dont introduce something new, regular
exercise or gentle if no previous exercise
lifestyle choices - stop drinking & smoking/drugs,
nicotine repla. therapy, quitline.

breastfeeding - health promotion, talk about the

benefits with the woman, bonding with babies as well
as health benefits for baby

ASSESSMENT
History
Pregnancy planned/unplanned
Medical
Medicines, family history, cervical screening, immunisation

Obstetric past pregnancies/births

Smoking, nutrition, alcohol, physical activity, drug use
Expectations, partner/family involvement, support, cultural
and spiritual, concerns, knowledge, pregnancy, birth,
breastfeeding and infant feeding

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preterm baby (< 27 wks)

ASSESSMENT
Clinical

Discuss conception, date of last menstrual period,

Ultrasound scan between 8 and 14 weeks (dating)
Measure height and weight (BMI) height x weight (m 2)

opportunity in birth to lose weight,

motivated for better outcomes in pregnancy,
health promotion

BMI <20 (underweight)

Preterm birth, small for gest age

BMI >25 (overweight)

Stillbirth, large for gest age, neural tube defects, diabetes, hypertension,
PPH, depressive disorders,

blood pressure is taken each visit

BMI > 30 (obesity)

Increased rate of LSCS, postpartum weight retention, inability to BF

Blood pressure
Urinalysis proteinuria
Mental health and psychological factors

protein in urine can impair function of urinary

system

Administer Edinburgh depression scale

asking women about chances of developing

postnatal depression, consult and refer if she
believes chances are high

ASSESSMENT
Screening
Blood group/antibody screen, FBC, haemoglobin
Offer testing

HIV
Hepatitis B, rubella, syphilis, asymptomatic bacteriuria
Hepatitis C to women with risk factors
<25 yrs and/or living in areas with a high prevalence of sexually
transmitted diseases chlamydia
Consider all women chlamydia and gonorrhoea testing

Consider vitamin D testing

Offer screening for chromosomal abnormalities 11-14 weeks

if baby and mums blood mixes, and baby has Rh

factor,
mother will produce antibodies that cross the
placenta,
triggering an immune response, causing a miscarriage
Anti D (made from human blood)
has been developed for Rh-ve women,
stops her from developing antibodies.
Vitamin D - dark skin, covered women, low vit D supplementation, prevents osteo
HARMONY test, expensive, goes to california

OVERALL ASSESSMENT

Estimated date of birth

Current problems
Risk factors
Need for referral

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ESTIMATED DATE OF BIRTH

Naegeles rule
1st day of the last menstrual period add 9 months and 7
days

all women with a 28 day cycle and ovulating around the same time

Enquire on the womans menstrual history

Individualise by altering cycle length adding or subtracting
days depending on what the woman states is her average
cycle length

ULTRASOUND SCAN
8 weeks 13+6 weeks
Overlaps dating scan and nuchal translucency
Can have both tests in one scan
Only performed with explanation and consent

Dating use crown rump length

Should be performed by a person with specific training
Repeated ultrasounds should only be performed when
clinically indicated
Aboriginal and Torres Strait islander women often live in
rural and remote
Access difficult for ultrasound scan

ESTIMATED DATE OF BIRTH

If LMP known and menstrual cycle regular compare
estimated date with ultrasound result
Ultrasound between 6-13 weeks
2 dates differ by <5days use LMP
2 dates differ by >5 days use US

Ultrasound between 13-24 weeks

2 dates differ by <10 days use LMP
2 dates differ by >10days use US
Due date should not be changed

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Urine screening
Urine test for asypmtomatic bacteriuria (persistent bacterial
colonisation of the urinary tract in the absence of specific
symptoms
Diagnosed as >100,000 bacteria/ml on midstream urine test
Risk of developing pyelonephritis and association with
preterm labour

PHYSICAL EXAMINATION
Abdominal palpation
Ausculatation of fetal heart rate

Measuring blood pressure

Abdominal palp, after 16 wks, determine position,

lie, attitude, engagement and position of the baby.
checking baby growth and heart rate,
checking baby wellbeing

Screening test for hypertension

Defined as 140/90
Then sub-defined
Essential/chronic
Gestational
Pre-eclampsia or super imposed pre-eclampsia

BP, syst 140, diast 90

Multi-system disorder particular to pregnancy difficult to prevent and

treat

White coat syndrome

ACTIVITY
Using the Australian Antenatal care guidelines
develop a plan for the following womans
antenatal care
Australian Guidelines for antenatal care

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PRACTICE BOOKING VISIT

29 yrs old well woman, currently working full time in
administration role close to the hospital
G2 P1
Last Menstrual Period 14th December 2014 (28 day cycle)
Due date?
Well woman with no medical or surgical history
No history of anxiety or depression
Well supported by her husband and extended family
Vietnamese background, born in Australia
Previous normal birth at term
Small 2nd degree tear healed well
Breastfed for 13 months
No complications in the postnatal period
Brian is a busy toddler attending at the visit

ONGOING CARE

16-19 WEEKS
Results from booking discuss
Morhphology scan ? Discuss implications/results
Physiological changes (minor disorders of pregnancy)
Nausea and vomiting should be resolving
Blood pressure measurement
Assess fetal wellbeing
Fundal height
Growth/movement
Auscultate Fetal heart rate
Discuss antenatal education plans
Infant feeding discussion
Diet, exercise, healthy lifestyle discussion
Measure weight if clinically significant
Identify if referral is required

morphology scan - see how baby looks, taken

around 19 wks gestation to detect fetal abnormalities,
location of placenta (low lying ie in front of babies
head, may impact on mode of the birth). As uterus
grows to accommodate growing fetus (from the
bottom) to allow more room, may cause low lying
placenta to no longer be low lying
ask open ended questions to promote information
sharing.
movements indicate good health of baby

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20-27 WEEKS
Results/implications of morphology scan
Screening
Blood Pressure

Assess fetal wellbeing

Fundal height
Size
Fetal movements discuss timing normal patterns
Heart rate

Diet, exercise, lifestyle, employment/family support

Discuss and offer second screening FBC, antibody
screen and diabetes screening for 28 weeks

28 WEEKS
Normal physiological changes
Check appropriate referrals eg mental health
Screen

BP
Diabetes screen
Full blood count
Blood group antibody screen

Rhesus negative women offer anti- D prophylaxis

Discuss breast changes and breast feeding
Begin to discuss signs of labour (detect pre-term labour)
particularly in rural and remote areas

At 28wks mother may experience physiological anaemia

needs to take iron supplement, inc. iron in diet
bladder irritability, more pressure on bladder
uncomfortable, breathing difficulty, sleeplessness
tired, fatigue, dizzy, avoid crowds
may feel practice (braxton hicks) contractions

29-34 WEEKS
Plans for birth discuss family changes
Discuss results of blood tests refer if necessary
Physiological changes
Sleeping patterns
Screen
BP
Assess fetal wellbeing discuss normal fetal movement patterns
Fundal height
Growth
Fetal movements
Auscultate fetal heart rate
Rescan if low lying placenta
Discuss preparation for labour and birth
Birth plan
Recognising active labour
Managing the pain of normal labour

talking about sibling adjustment

insomnia, common in pregnancy - suggest
relaxation exercises, pelvic floor exercises
normalising labour, place of birth, how she will
know that she is in labour

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35-37 WEEKS
Screen

BP
Rh antibody screen and offer anti D prophylaxis
Repeat FBC if previously abnormal assess effectiveness of taking iron
Haemolytic Group B streptococcus vaginal swab risk versus routine
Review ultrasound if performed for placenta location
Offer Group B Streptococcus screening

if she has low haemoglobin levels (<90 -100), offer

an iron supplement and advise on diet changes to
increase iron, read bottle for dosage and percentage of iron to
determine effectiveness of supplement
If this avenue doesnt work, refer to GP

Fetal wellbeing

Movements
Fundal height/growth
Assess presentation by abdominal palpation US for suspected
malpresentation
Discuss options or malpresentation external cephalic version

Group B strep may be contracted by baby, causing

pneumonia, screening can prevent this. done at 35 -37 wks
(close to birth) as this bacteria is transient, grows randomly.
antibiotics can kill them to eliminate the risk to the baby
Assess presentation, is it transverse, cephalic, or breech?

38-40 WEEKS
Review signs of labour what to expect, how to contact the midwife
Discuss

Fetal movements
Vaginal bleeding
Ruptured membranes
Physiological changes
EDB
Results of Blood tests/vaginal swab
Length of pregnancy, onset of labour, any fears or worries

Screen
BP

Assess fetal wellbeing

movements will be in a pattern, sleep, wake cycle

is baby moving normally according to pattern?
softening of cervix may cause vag. bleeding, in prep for labour
waters may break before labour (20-30%)
heavy, fatigued, insomnia, belly drops as head engages
causing more pressure on the bladder, fundus drops, sore
back, aches and pains, shouldnt be @ work.

Fundal height/growth/movements

discuss her fears and worries, explore those, understanding

inducing baby isnt a good idea, as baby may not be
developed properly - mistakes or errors in estimated date of
birth

41 WEEKS

Discuss prolong pregnancy

Offer membrane sweep
Measure blood pressure
Assess fetal wellbeing
Fundal height/growth/movements

Consult and refer

overdue
memb sweep, may initiate labour and reduce induction,
depends on consent.
midwives scope of practice doesnt involve inducing
labour as that requires prescriptions, drugs etc.

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PROVIDING CARE FOR WOMEN WITH

MENTAL HEALTH DISORDERS
Assess all women for high prevalent mental health
disorder depression and anxiety
Women who experience mental health disorders require
care provided in collaboration with a mental health
specialist/continuity of care from treating clinician
Discuss current psychotropic medication, ongoing
treatment, risk/benefit
Offer preventative treatment for women at risk of bipolar
or postnatal depression
If there are concerns about a womans attitude to the
fetus or capacity to manage parenthood, relevant
agencies (eg child protection services) are involve

reporting to DOCS if at risk of harming children

PROVIDING CARE FOR MIGRANT AND

REFUGEE WOMEN
Migration factors
History of grief, loss and trauma
Lack of knowledge of Australian Health care system
Arriving late in pregnancy
Cultural factors
Adherence to cultural/religious practices
Poor language proficiency
Position in host country
Unemployment/financial problems
Low education level
Social inequity
No leave from work

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PROVIDING CARE FOR MIGRANT AND

REFUGEE WOMEN
Social Network
Lack of usual female family, community supports
Accessibility
Transport
Inappropriate timing and incompatible opening
hours
Health professional lacking knowledge of cultural
practices
Special groups
FGM, diabetes, smoking, vitamin D deficiency
Provide multicultural health worker and interpreter

ONGOING CARE ACTIVITIES

Module 1: Australian Health Ministers Advisory

Council 2012, Clinical Practice Guidelines:
Antenatal Care Module 1. Australian Government
Department of Health and Ageing, Canberra.
http://www.health.gov.au/antenatal

Module 2: Australian Health Ministers Advisory

Council 2014, Clinical Practice Guidelines:
Antenatal Care Module 2 Australian Government
Department of Health and Ageing, Canberra.
http://www.health.gov.au/antenatal

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