antenatal care for midwives

1. Antenatal care
• Midwifery led care for all uncomplicated pregnancies involving 10
appointments over the course of a pregnancy for nulliparous women and 7
if it is a second pregnancy.
• Obstetrician led care If women are classed as higher risk including multiple
pregnancy, maternal health problems and consists of all the midwifery
appointments PLUS joint clinics to cover mental health, hematological
issues, diabetes etc.
• The Booking Visit is the first (and arguably the most important antenatal
appointment) where an in-depth history and discussion takes place.

3. Vitamins in Pregnancy:
• *Women at high risk of neural tube defects require a higher dose of folic acid (5mg in the
first trimester, in particular those with certain medical conditions which include:
• Epilepsy
• Previous baby with neural tube defects
• Obesity with BMI over 35
• Diabetes (Type 1 and 2)
• Sickle cell disease
• Thalassemia
• Malabsorption disorders (e.g. Crohn’s disease)
• Those taking folate antagonist drugs (HIV anti-retroviral drugs, methotrexate,
sulphonamides)
• It should be taken ideally 3 months before pregnancy and up to the first 12 weeks.
• *Offer all women Vitamin D (10 mcg) per day to reduce the risk of rickets. Women with
darker skin, those from any BAME group (Black/Asian/Caribbean) or with a BMI >30
should have a higher dose.

4. Rhesus D status:
• All women have maternal blood grouping and Rhesus typing at the
booking visit. If detected:
• Administer Anti-D AB to Rhesus D negative women at:
• Sensitizing events (amniocentesis, antepartum bleed and abdominal
trauma)
• Check the dose of Anti D required with the Kleihauer-Betke test after
a sensitizing event.
• Routinely offer prophylaxis at 28 and 34 weeks.
• Learn more about red cell isoimmunization here.

5. Fetal Growth:
• Symphysis fundal height (SFH) should be measured at each antenatal appointment
after 24 weeks.
• If there are concerns, send for an ultrasound assessment.
• It is important to risk assess for possible growth restriction at the first and subsequent
appointments.
• Other indications for these regular USS are:
• Multiple pregnancy
• BMI >35
• Large or multiple fibroids
• This is because these mothers are unsuitable for SFH measurements, as abdominal
palpation is unlikely to be accurate in these instances.
• Consider low dose aspirin at night from 12 weeks gestation as this is known to reduce
the incidence in those who are high risk of having a small for gestational age fetus.

12. Osce obstetric examination
• The obstetric examination is a type of abdominal examination performed in
pregnancy.
• It is unique in the fact that the clinician is simultaneously trying to assess the
health of two individuals – the mother and the fetus.
• In this article, we shall look at how to perform an obstetric examination in an
OSCE-style setting.
• Introduction
• Introduce yourself to the patient
• Wash your hands
• Explain to the patient what the examination involves and why it is necessary
• Obtain verbal consent

13. • Preparation
• Measure the patient’s height and weight
• In the UK, this is performed at the booking appointment, and is not
routinely recommended at subsequent visits
• Patient should have an empty bladder
• Expose the abdomen from the xiphisternum to the pubic symphysis
• Cover above and below where appropriate
• Ask the patient to lie in the supine position with the head of the bed
raised to 15 degrees
• Prepare your equipment: measuring tape, pinnard stethoscope or
doppler transducer, ultrasound gel

14. General Inspection
• General wellbeing – at ease or distressed by physical pain.
• Hands – palpate the radial pulse.
• Head and neck – melasma, conjunctival pallor, jaundice, oedema.
• Legs and feet – calf swelling, oedema and varicose veins.
Abdominal Inspection
In the obstetric examination, inspect the abdomen for:
• Distension compatible with pregnancy
• Fetal movement (>24 weeks)
• Surgical scars – previous Caesarean section, laparoscopic port scars
• Skin changes indicative of pregnancy – linea nigra (dark vertical line from umbilicus
to the pubis), striae gravidarum (‘stretch marks’), striae albicans (old, silvery-white
striae)

16. Palpation
• Ask the patient to comment on any tenderness and observe her facial
and verbal responses throughout. Note any guarding.
• Fundal Height
• Use the medial edge of the left hand to press down at the
xiphisternum, working downwards to locate the fundus.
• Measure from here to the pubic symphysis in both cm and inches.
Turn the measuring tape so that the numbers face the abdomen (to
avoid bias in your measurements).
• Uterus should be palpable after 12 weeks, near the umbilicus at 20
weeks and near the xiphisternum at 36 weeks (these measurements
are often slightly different if the woman is tall or short).
• The distance should be similar to gestational age in weeks (+/- 2 cm)

17. Lie
Facing the patient’s head, place hands on either side of the top of the
uterus and gently apply pressure
Move the hands and palpate down the abdomen
One side will feel fuller and firmer – this is the back. Fetal limbs may be
palpable on the opposing side

18. Presentation
• Palpate the lower uterus (below the umbilicus) to find the presenting part.
• Firm and round signifies cephalic, soft and/or non-round suggests breech.
If breech presentation is suspected, the fetal head can be often be
palpated in the upper uterus.
• Ballot head by pushing it gently from one side to the other.
• Liquor Volume
• Palpate and ballot fluid to approximate volume to determine if there is
oligohydramnios/polyhydramnios
• When assessing the lie, only feeling fetal parts on deep palpation suggests
large amounts of fluid

19. Engagement
Fetal engagement refers to whether the presenting part has entered the bony pelvis
Note how much of the head is palpable – if the entire head is palpable, the fetus is
unengaged.
Engagement is measured in 1/5ths

20. Fetal Auscultation
• Locate the back of the fetus to listen for the fetal heart, aim to put your
instrument between the fetal scapulae to aim toward the heart.
• Hand-held Doppler machine >16 weeks (trying before this gestation
often leads to anxiety if the heart cannot be auscultated).
• Pinard stethoscope over the anterior shoulder >28 weeks
• Feel the mother’s pulse at the same time
• Measure fetal HR for one minute
• Should be 110-160bpm (>24 weeks)

21. • Completing the Examination
• Palpate the ankles for oedema and test for hyperreflexia (pre-
eclampsia)
• Thank the patient and allow them to dress in private
• Wash your hands
Summarise findings
• Perform:
• Blood pressure
• Urine dipstick