Antenatal care aims at maintaining the good health of the mother during pregnancy which will enable her to produce a healthy, normal infant and remain so herself. It is greatly concerned with health education during pregnancy to ensure the maximum preparation of each individual for her labour and role of motherhood. One of its outstanding features is the early detection of any condition which might adversely affect the health of the mother or her baby.
The History of Antenatal Care
Antenatal care is a comparatively new approach to childbirth and has only developed since the beginning of this century. Before 1900 women had no care during pregnancy and were seen for the first time by a doctor or midwife when labour had become established so that complicating factors were never discovered until late in labour. The results were disastrous. Women died in childbirth and their babies were fortunate to survive.
The serious study of pregnant women began in 1901 in Edinburgh and has been developed throughout many countries. Advances in the care of pregnant women are still continuing and today in this country it is difficult to realize the situation of the past. Today women have nothing to fear from pregnancy and labour, the outcome of which is a happy event in any family unit.
Very few aspects of medicine have changed so dramatically and radically as the care of the pregnant woman over the past forty years. The introduction of antibiotics and the consequent control of infection have affected all branches of medicine, not least of all women during and immediately after childbirth. However, the complete antenatal care as we now know it is an entirely new concept not even dreamed of forty years ago. It has moved most of the responsibility for the pregnancy from the pregnant woman herself to her professional adviser, be that doctor or midwife. The maternity services, as represented by the doctor and midwife, have cheerfully and gladly accepted the responsibility of looking after the pregnant woman. The history of antenatal care is one which will stand repeated examination.
Forty years ago antenatal clinics as we now know them did not exist. The pregnant woman either wrote to or went to see her doctor, midwife or hospital in order to book a place for her confinement. When she had done this she returned home and awaited the onset of labour, or some complication which might befall her during her pregnancy. If the pregnancy proceeded normally and labour duly arrived, the doctor or midwife was summoned at a time determined by the pregnant woman and her husband, or other members of the family brought in to give appropriate advice.
Complete antenatal care is the ideal type of preventive medicine for which doctors have been searching for many generations. Complications can be recognized sufficiently early to be corrected. Tests and other investigations can be performed to detect those patients in whom a complication might arise so that treatment can be given to prevent its occurrence. Even for those who are destined to have a perfectly normal pregnancy, labour and delivery, helpful guidance, reassurance and instruction will help to make their pregnancy a pleasure rather than a duty.
The importance of antenatal care cannot be over-emphasized nor can the benefits that good antenatal care bestows upon the pregnant woman be overstressed.
Statistical evidence in the Perinatal Mortality Survey shows that the earlier a pregnant woman presents herself to her professional adviser for her first antenatal visit the higher is the chance that she will have a perfectly normal pregnancy and healthy baby. Also, the longer she defers her first visit, the greater are the chances of her having some complication of pregnancy or a dead baby. It is astonishing, with these facts in mind, that only about 5 per cent of women attended for their first antenatal visit during the’ first 8 weeks of pregnancy, and that almost 50 per cent of women failed to attend until after the 16th week of pregnancy. The same report also shows that the chance of a woman producing a live, healthy, normal infant is directly related to the number of antenatal visits she makes with a reasonable limit.
For many years obstetricians and midwives have been accused by their patients, often quite rightly, that they keep them ‘in the dark’ and tell them nothing, and that pregnant women have to obey a long list of rules and regulations without knowing why. When antenatal clincs were new, doctors and midwives were themselves searching for the reasons why some pregnant women developed complications, and why some babies died. It was not until after the 1939/45 war that the answers to some of the problems gradually became apparent, but meanwhile the accent was, and still is, on reassuring the pregnant woman who is intensely receptive to suggestion. She needs assurance that her pregnancy is going well, and it is extremely difficult and often impossible for the doctor to say to her ‘Because such and such has happened I am afraid the chances of your baby dying are automatically doubled.
As professional advisers have learned the answers to their patients’ questions they have still thought it inadvisable to answer these questions directly because of the worry this might cause the patient herself. Imagine the reaction of a patient who first attends the antenatal clinic at the 30th week of pregnancy on being told that she should have attended the clinic at the 8th week of pregnancy and, on enquiring why, is then told that by this neglect the chances of her child surviving are considerably reduced.
During the past ten to fifteen years women have become more inquisitive concerning the process of labour and their delivery and their seeking for information is to be encouraged. Even so, some women are frequently screened from some of the true or more unpleasant facts if these might disturb them.
Many pregnant women today want to know more about the process of pregnancy and what they can do to ensure its success. Their questions should be answered honestly and sympathetically and they in turn must accept the honesty of the answers they are given. If they enter into a phase of grey depression when they are told that a certain risk is present and do not accept that the risk is not a finality, doctors will refuse to disclose information to their patients.
The majority of doctors and midwives recognize that only knowledge can eliminate fear and depression. They are now attempting to remove the mystique which has always surrounded pregnancy and labour so that pregnant women and their husbands will understand not only the physiology and anatomy, but also the signs and symptoms of complications as well as the methods of dealing with them and their prevention. The effort to replace ignorance with knowledge and understanding is gaining momentum from the combined efforts of midwives and doctors as well as from women themselves.
The vast majority of maternity units under the National Health Service in Great Britain have a course of classes for patients who are attending the antenatal clinic of the hospital. Similar antenatal classes are run by many local authorities for women who are having their babies at home. The majority of these courses include lectures and discussions on pregnancy, labour, delivery, the care of the new-born baby, clothes required during pregnancy and for the newborn infant, as well as visits to the wards and delivery room, instruction and practice in the use of gas and oxygen machines and other simple equipment that may be required during labour. Relaxation classes are usually run parallel with the courses of instruction. A dietician is available to give advice on diet during pregnancy and a social worker to offer advice and help to those who need it. The majority of units also encourage husbands to attend one or more of these discussions or lectures.
The whole concept of this type of antenatal care and instruction is to offer helpful information and to create trust, confidence and understanding between the patient and the people who are going to look after her. Fear and misunderstanding are replaced by knowledge and a confident appreciation of the reasons behind the meticulous care that is taken of a woman during pregnancy.
Many changes through the years have been responsible for the progress in obstetric practice. Their effect has been cumulative since no single factor could have changed pregnancy from the days of ignorance, disease, damage and death, to the present haven of knowledge, safety, happiness and health of the mother and her child.
Obstetricians, doctors who specialize in midwifery, have had an immense amount of training.
Midwives have advanced training and they too are experts in the care of women in normal pregnancy, labour and the puerperium. The midwives and obstetricians co-operate to achieve maximum benefits for all under their care.
Anaesthesia. Improvements in the methods of anaesthesia during labour have been an important factor in the evolution of the maternity service.
Paediatricians are trained to care for babies and, with the co-operation that exists between obstetricians and paediatricians, the survival rate of all babies, especially that of the small premature baby, has improved.
General practitioners have been trained in modern methods of maternity care and are encouraged to help in the antenatal supervision of their patients who are to be delivered in hospital. They seek help and advice from specialist obstetricians concerning those patients whom they are looking after at home or in a General Practitioner Maternity Unit. All the facilities of the Health Service are at their disposal.
Blood transfusion is now safe and this development has done much to ensure the safety, and indeed the lives, of many woman. The early diagnosis and virtual elimination of anaemia has had a profound influence upon pregnancy and its management.
Bacteriological advances have done much to eliminate infection during and after delivery and this, combined with the discovery and widespread use of antibiotics, has probably saved more lives than any other recent discovery.
X-ray and other techniques such as ultrasonics have improved and are invaluable aids to obstetricians.
Health visitors, dieticians, social workers, laboratory technicians and physiotherapists are all concerned with pregnancy. These people are highly trained specialists who augment the work of the obstetrician.
Many safe drugs, in addition to antibiotics, are now available for the treatment of abnormalities in pregnancy, labour and the puerperium, as well as for the treatment of the baby.
The hospital maternity units form a centre of co-operative effort, seldom seen in hospital medicine, that is designed especially for the care and welfare of the pregnant woman. Both simple and complicated equipment have been designed to make maternity care more efficient.
The pregnant woman herself, however, is the most important factor in the management of pregnancy. She must learn to look after her unborn baby during the nine months of her pregnancy with the same amount of care that she will take of him after he is born, and to do this she must know all about her pregnancy.
The First Visit to the Antenatal Clinic
The first visit to an antenatal clinic can be quite an ordeal, particularly if it is the first time a woman has set foot inside a hospital. All fears are groundless. Pregnant women are just about the only fit and well people who ever attend as patients in a hospital or go to the doctor. Most know and trust their doctor; he (or she) is one of the best friends they could possibly have—perhaps not yet, but he will be, especially if he is going to look after them. Perhaps he is married, perhaps he has children; he is human and, like his patients, has loves and hates, fears and friendships, likes and dislikes. He is an ordinary human being who happens to have been trained to practise medicine and look after people.
The general practitioner, the domiciliary midwife and the doctors and midwives who work in the hospital are all particularly and specifically trained to take care of women during their pregnancies. They understand the fears and apprehensions, as well as the joys and excitement, that beset a woman at the beginning of her first, or indeed at the beginning of any, pregnancy. As pregnancy progresses the woman gets to know the people who are looking after her, so that after the baby has arrived she wonders how she ever managed without them. They become friends and advisers because they know that in this way they have a happier and more co-operative patient to look after. Obstetrics and midwifery are vocations which doctors and midwives follow because they enjoy their roles. They are intensely dedicated professions. There is no need for any woman to approach her first antenatal visit with fear and trepidation. She will find it most interesting, especially if she knows what to expect.
The Antenatal History
In every pregnancy it is essential to acquire as much information as possible about each new patient at the earliest opportunity. This is usually obtained at a quiet, unhurried, interview between the obstetrician or the midwife and the patient. The details of the history that are required may seem superfluous and, in order to try and classify them in a more easily understandable fashion, we will consider them under separate headings.
Social history. This is one of the most important considerations concerning any pregnancy. You will be asked your full name, age, date of birth and country of origin. How long have you been married? How long have you been trying to get pregnant? What contraceptive, if any, have you used? What work did you do before you married (or are you doing now) ? What is your husband’s occupation ? Details may also be required about your housing accommodation, especially if you hope to have your baby at home or return home shortly after your delivery in hospital.
Family history. Is there any family history of twin pregnancy, diabetes or any type or form of congenital abnormality ?
Medical history. Have you yourself suffered from any particular medical conditions, especially any disease of the heart, lungs or of the kidneys? What infectious diseases have you had, with special reference to rubella (German measles) ? Do you smoke ? If so, how much?
Surgical history. Have you had any operations, broken bones, serious accidents or blood transfusions?
Menstrual history. The doctor will want to know the age at which your periods began, your normal menstrual cycle together with the number of days your periods usually last, and the date of the onset of your last normal, regular period.
Obstetric history. If you are not pregnant for the first time, perhaps the most important part of the history is to record information about your previous pregnancies. This will include particulars of any miscarriages as well as dates of deliveries together with the weights of the babies and details of your labours.
The present pregnancy. Finally you will be asked for details of your present pregnancy, and these will probably include a request to know your weight at the beginning of the pregnancy and a list of the symptoms that you may have had since you first realized you were pregnant.
Once doctors or midwives have all this information, they have a pretty good picture of you, but what is perhaps more important is that they also have an idea of what you expect from them.
Assessment of the woman’s health at this stage is, of course, most important and after the interview in which the details of your history have been taken, you will undress for examination.
Height. This is important because it gives a rough estimate as to the size of the bony pelvis for childbearing. In Britain women over 5 ft. in height nearly always have pelvic bones of adequate size (as do women who take average sized shoes) and, indeed, those who are less than 5 ft. tall often have an adequate pelvis.
Weight. One aspect of antenatal care is weight control in pregnancy. You will be weighed early in pregnancy and then at each visit to the antenatal clinic, to calculate weight gain. It is essential to allow only an 18-20 lb. weight gain during the whole pregnancy. Diet in pregnancy is most important. You may be asked if you normally diet to keep your figure.
Urine is tested at the first and at every subsequent antenatal visit. At the first visit a special specimen, called a mid-stream specimen, is sometimes obtained after washing the external parts of the vulva to ensure that there is no contamination and that the urine is especially ‘clean’. You will be told how to collect this specimen at the time. This is sent to the laboratory for particular examinations to exclude any abnormalities such as unsuspected infection. A small amount of the specimen is tested in the clinic for protein and sugar which, if present, are significant in your antenatal care. You may be requested to bring a dean specimen of urine in a clean container to the antenatal clinic at each subsequent visit. The second specimen of the day is preferable to the first.
Blood pressure. Your blood pressure will be taken and recorded at your first visit and at every subsequent antenatal visit. The blood pressure recording at the first visit is most important because only variations from this level are really significant. A rise in blood pressure is one of the less welcome signs of pregnancy and often indicates the possibility of a complication. One of the commonest abnormal conditions in pregnancy is pre-eclampsia and it is only by careful assessment of the blood pressure that this condition can be detected sufficiently early to be treated successfully.
The breasts are examined for signs of pregnancy and evidence of their activity. Their condition and the state and condition of the nipples are noted, especially if you wish to breast-feed your baby. They are also examined by a midwife who gives appropriate advice on their care during pregnancy.
A general medical examination is carried out either by your general practitioner or by a doctor at the antenatal clinic to assess mental as well as physical health. It is surprising how much can, in fact, be noted purely by observation.
Head and neck. The state of your hair, the colour of your eyes, the condition of your teeth, any evidence of pallor or anaemia, any indication of enlarged veins in the neck or swollen thyroid can be noted by a doctor without touching you.
Chest. The heart and lungs are examined by stethoscope although this may be purely a formality in a young healthy woman who has never suffered from any disease.
Abdomen. The abdomen is examined at the first and at every subsequent visit to the antenatal clinic. At the first visit the uterus is usually quite small and all the other organs can be palpated to assess their normality. The size of the uterus is noted and compared with the estimated date of delivery. If you are more than 16 weeks pregnant you may be asked if and when you have felt foetal movements. The exact date at which you first feel the baby move may be rather difficult to define but you should make a note in your diary as soon as you are certain that you have felt it and tell the clinic this date at your next visit. If you are more than 12 weeks pregnant the size and duration of the pregnancy may be confirmed by listening to the baby’s heart with electronic equipment such as a Doptone or Sonicaid.
Limbs. Your pulse will be taken and any swelling of the fingers which might be making rings unduly tight is noted. The condition of the fingernails may indicate any possible anaemia and reveals much about character and how hard a person works. They are very revealing. The legs are examined for evidence of varicose veins or swelling of the feet or ankles.
Vaginal Examination during Pregnancy
A vaginal, internal or pelvic, examination is usually performed at the first visit to the doctor or to the antenatal clinic:
1 To confirm the presence of the pregnancy.
2 To confirm that the size of the uterus is in agreement with the suggested duration of the pregnancy.
3 To ensure that the pregnancy is normal.
4 To exclude the presence of any tumours or other abnormalities in the pelvis.
5 To diagnose any infections in the vagina or cervix.
6 To diagnose the presence of an ulcer or erosion on the cervix.
7 To take a routine cervical smear to exclude disease or cancer of the cervix.
8 To assess the size of the cavity of the pelvis.
9 To assess the size of the outlet to the pelvis.
A vaginal examination may be performed at other times during pregnancy but generally it need not be repeated until the 36th week when it is performed:
1 To confirm the presentation of the baby.
2 To assess the condition of the cervix.
3 To confirm the size of the bony pelvis.
The assessment of the bony pelvis is easier at the 36th week than in the earlier stages of pregnancy. This assessment is particularly important in a woman having her first baby, especially if the head is not by then engaged within the pelvis. If the head is engaged at the 36th week a vaginal examination may not be performed since the cavity of the pelvis must be adequate for the head and the pelvic outlet had been assessed at the beginning of pregnancy.
Blood tests are of vital importance during pregnancy. Blood will nearly always be taken at the first antenatal visit to either the clinic or doctor, and a series of tests will usually be performed upon this sample.
A haemoglobin estimation. This is an estimation of the quality and the density of the red cells in the blood. It is expressed either in gm. or simply as a percentage; 14.7 gm. is equivalent to 100 per cent. The normal haemoglobin level in the non-pregnant woman is approximately 13 gm. or 90 per cent. During pregnancy it falls, but should never be less than 12 gm or 80 per cent. If it does fall below this figure the woman is said to be anaemic.
Blood grouping. People belong to one of four major blood groups— A, B, AB or O. This knowledge is important not only in case a blood transfusion is necessary at a later stage but because in very rare instances incompatibilities between the mother and her baby may arise when they have different major blood groups.
Rhesus factor. It is important to know if the woman is Rhesus negative or positive . If a woman is Rhesus negative a test for Rhesus antibodies is performed.
A Wassermann reaction. This is a routine screening test for the presence of syphilis. Some patients become very indignant when they realize that a testis being performed for syphilis but it is of the utmost importance. Syphilis is a disease which can be transmitted to the unborn child after the 20th week of pregnancy. Adequate treatment before the 20th week of pregnancy will prevent its transmission to the foetus. If a woman is unaware that she has the disease and is not treated her child can be severely and unnecessarily affected. In some units the Wasserman Reaction has been replaced by other, similar, blood tests.
Other Blood Tests
Some hospitals routinely test patients’ blood for alpha foetoprotein (A.F.P.) which is high when the baby has spina bifida. Routine testing for German measles (rubella) may be performed.
Blood is taken for haemoglobin at intervals throughout the pregnancy, and if anaemia is discovered, more complicated tests may be required.
At the first visit to the antenatal clinic the dietician should be available to give details about diet in pregnancy. Early pregnancy is the time to discuss diet and weight control as it is easier to be strict about forbidden foods from the very beginning.
The Medical Social Worker
The medical social worker is available to see women who have social problems.
Iron and Vitamins
Iron and vitamin tablets are given routinely to most pregnant women. The iron pills come in various sizes and contain different preparations of iron. The vitamin pills similarly contain varying amounts of different vitamins. Generally speaking all these iron and vitamin pills are adequate and satisfactory.
Iron is essential to prevent anaemia which was, until a few years ago, so common in pregnancy that it was considered normal. It is now comparatively rare and your haemoglobin level should stay well above 11 gm. (75 per cent) throughout the whole pregnancy. A more recent addition to the range of vitamins administered is folic acid which is now given routinely to prevent a particular type of anaemia which occurs during pregnancy, known as megaloblastic anaemia, and which, without this treatment, affects 5 to 7 per cent of pregnant women in Great Britain.
Iron and vitamin tablets are not usually supplied until after the end of the 14th week of pregnancy for two reasons. Firstly, although they are all quite safe, there is an inherent dislike of giving any tablets to any woman during the first 12 weeks of her pregnancy. Secondly, iron tablets can cause disturbance of the intestine and lead to either constipation or diarrhoea, occasionally to nausea and in some circumstances to actual vomiting, and therefore are not given until the nausea which most women experience to a greater or lesser degree during the early part of pregnancy has passed. If iron tablets do cause discomfort, constipation, diarrhoea or nausea, this should be mentioned at the next visit to your doctor or the clinic. People’s reactions to different iron preparations vary considerably and any upsetting symptoms will probably disappear completely with another type of iron tablet. Some people who are extremely intolerant of all iron tablets may have to be given iron injections.
There are no side effects from vitamin pills or folic acid tablets.
Subsequent Visits to the Antenatal Clinic
Subsequent visits that you make to either the doctor or the antenatal clinic follow a standard routine unless for some reason the doctor wishes to see you earlier.
Visits are usually every four weeks until the 28th week of pregnancy. Thereafter they are every two weeks until the 36th week and then every week until delivery. At each visit to the clinic you will be weighed, your urine tested, your blood pressure taken and recorded and your abdomen and ankles inspected. Unless there is some specific reason for another internal examination, it is not again performed until the 36th week. Blood samples are taken at intervals and more frequently if there is evidence of anaemia.
As pregnancy progresses the normal milestones are carefully recorded, and slowly but gradually a complete picture of the pregnancy emerges. Any variation from normal in the woman, her uterus or her baby is carefully noted and corrective measures are taken. Your co-operation and understanding are, of course, essential, for without them proper care during pregnancy is impossible.
If you have questions that you would like to ask the doctor or the midwife when you visit the antenatal clinic, make a note of these on a piece of paper and take it with you. Most antenatal clinics are rather busy and there is not a great deal of time for answering irrelevant queries. In practice, however, there is always time and you can ask your questions quickly and simply from a list.
The whole art of looking after and taking care of a pregnancy is the preventive medicine that takes place in the antenatal clinic.
From about the 28th week until the end of pregnancy a doctor or midwife can feel the baby as it lies within the uterus and can also define quite accurately the position in which the baby is lying even to the extent of feeling its hands and feet. A baby normally sits on its bottom with its head at the top of the uterus until about the 30th or 32nd week of pregnancy, when for some unknown reason it turns head downwards. It can thus prepare the pelvis and the lower part of the uterus for its subsequent delivery which occurs head first. If the baby does not turn round spontaneously by the 33 rd or 34th week of pregnancy the doctor may do an external version. By gently palpating the baby through the anterior wall of the abdomen and the uterus, the baby is turned so that its head instead of its bottom is lying over the brim of the pelvis. A skilled doctor can do this without the mother realising that the baby is being turned or even moved. In 96 per cent of pregnancies the baby’s head is presenting which means that the baby has turned round spontaneously. It is important for the obstetrician to know which part of the baby is presenting at the brim of the pelvis because in the 4 per cent where the breech is presenting, either external version must be performed or adequate plans made for the breech delivery.
Even when the head is known to be presenting, it is most important that its exact position should also be known.
During a first pregnancy lightening normally occurs at about the 36th week. This is the result of the baby’s head descending into the actual cavity of the pelvis, which is known as engaging. In sub-sequent pregnancies the head does not usually engage until the expected date of confinement or the onset of labour.
Engagement of the head in the pelvis does not mean that labour is imminent. It does mean that the size of the pelvis is adequate for the baby’s head and that everything is progressing satisfactorily. The date of delivery cannot be predicted from the date of engagement.