ANTENATAL CARE.

OK, so you’re pregnant! What can you expect, and from who?

What type of antenatal care should I choose?

There are two types of antenatal clinic to choose from:

  • Public Hospital Care.  Low risk pregnancies are managed by the midwife with or without your GP.  You’ll have a handheld record where visits are recorded.
  • Private antenatal care following a referral from your GP. Care is led by a private obstetrician with their midwife.

Tell me more about public hospital antenatal care!

The GP refers you to your local public hospital. The hospital will accept the referral based on:

  • You living in their ‘catchment area’
  • The GP attaching routine test results

There are two ‘types’ of routine public hospital antenatal care:

  • GP Shared care: you see your GP during the pregnancy, and the hospital ‘only’ see you at the major landmarks, and then ‘take over’ completely towards the end of your pregnancy.
  • Midwife-led care: you ‘only’ see the midwife / hospital team during your pregnancy. Of course you may see your GP for any reason, but all routine appointments are at the hospital. Care is tending to move towards this at least in Brisbane.

Your first hospital antenatal clinic visit with the midwife and/or obstetrician will be at around 16 weeks, with further visits at 28 weeks, 34 weeks – and after that depending on circumstances. This interface between GP & hospital antenatal care is carefully informed & structured according to detailed guidelines from the RACGP, RANZCOG, Queensland GovernmentBrisbane’s Mater Hospital (for example).

You carry your “shared care” antenatal health record to all GP or hospital appointments. This shared care record is where the doctor and/or midwife write notes. That way,  everyone including yourself knows exactly where you’re at and what has been discussed. The GP, hospital midwife & Obstetrician all communicate via letters and by updates in your shared care record. The book also indicates what appointments and tests are due & when.

What is the role of a GP?

You may consider your GP as the specialist in the first trimester.

GP Shared maternity Care in The Three trimesters of pregnancy

Antenatal Care is divided fairly neatly into the 3 trimesters of pregnancy.

  • 1st Trimester: weeks 1 through to 12
  • 2nd Trimester: weeks 13 through to 27
  • 3rd Trimester: weeks 28 through to the delivery of the baby
First Trimester Screening in general practice

1st Trimester antenatal care

Your GP is normally your specialist in first trimester care including first trimester screening.

Your first 12 weeks are a time of tremendous change in your body. Your body is developing the home that will grow and nurture your baby (or babies!) for 40 weeks. It is important to understand that every pregnancy is different. You may experience some of the following symptoms with each pregnancy you have and you may never experience any of these symptoms.

  • Fatigue
  • Tender or swollen breasts
  • Bloating, cramping, or low back ache
  • Frequent need to urinate
  • Nausea with or without vomiting
  • Dizziness and fainting
  • Constipation
  • Headache

Conception begins about 2 weeks before you last period would have been due. It takes a little less than a week (about 6 days) for your newly fertilized baby to make the trek from your fallopian tube to your uterus. Once it arrives in the uterus, it will implant in the lining and begin to release the hormone human gonadotrophin hormone (HCG). The presence of this hormone is the basis for pregnancy tests. Both over-the-counter &  the medical centre pregnancy tests are the same and there is generally no need to confirm a positive test!

By 6 weeks from the date of your last period, the volume of blood in your body will have increased by 50%. Your metabolism will have increased by about 20%. This combination of increased metabolism and increased volume of blood may make you feel warmer, sweat more (especially in the feet and hands), and will result in your body temperature increasing from 37°C to 37.8°C.

Routine antenatal clinic Visits in the 1st trimester

During your first trimester, your visits to the Medical Centre to see your GP will consist of tests aimed at determining the viability of the pregnancy, the fetal number, the normality of the fetuses, and identify and develop a management system for any underlying emotional or medical conditions.

Your first visit will take longer than your other visits. If you want to invite your partner or a close friend or family member to come with you that is fine with us. It gives them a great opportunity to get involved with the pregnancy and get a feel for what will be happening over the coming months. Along with information about lifestyle and prior pregnancies, you will be asked to provide a detailed medical history as well as a family medical history. Based on the date of your last period, an estimated delivery date (EDD) will be calculated. Bear in mind that the expected date of delivery is very much an approximate date of delivery. The word expected is misleading.

If you smoke, your GP can refer you to resources to help you quit. It is very important to the development of your baby that you do not smoke or drink alcohol while pregnant.

Nutrients in pregnancy

A healthy diet and a reputable pregnancy supplement is a good place to start.

However, additional supplement may be required for individual nutrients.

Folic acid (at least 0.4mg) is included in all reputable pregnancy supplements. A higher 5mg of folic acid is also recommended for women whose BMI is over 30, or have multiple pregnancy. In addition, the 5mg dose is recommended for women who have a family history of neural tube defects, take anticonvulsants, or have a pre-pregnancy diagnosis of diabetes.

Other nutrients included in pregnancy supplements are Vitamin B12, Vitamin D, Calcium, Iron and Iodine. However, you may need extra supplementation of specific nutrients.

Vegetarians will need at least 2.6 ug per day of Vitamin B12.

Women who have a low vitamin D level will generally need 1000IU to 2000IU per day.

Calcium is a tricky one. The guidelines suggest 1000mg per day of dietary calcium so uou may need additional calcium supplementation. Use this calcium dietary calculator, and check the dose of calcium already in your pregnancy supplement.

Iron Defiency in Pregnancy

There are good arguments to treat iron deficiency in pregnancy before anaemia occurs¹. The main reasons are:

  • It is easier to treat mild iron deficiency because lower doses of iron tablets are better tolerated
  • Treating simple iron deficiency will prevent iron deficiency anaemia. Iron deficiency anaemia is associated with reduced fetal growth, low birth weight and preterm birth.

Ferritin is the best measure of iron. The “normal range” varies between 15 and 30. The average birth results in 500mls of blood loss which is equivalent to 30 ug/L of ferritin.

Therefore, many doctors will suggest adding “iron studies” to the battery of blood tests done at the beginning of the pregnancy, and treating low ferritin proactively.

The dose of “elemental iron” required to replenish iron stores is at least 100mg per day. Normal multi-vitamin pregnancy supplements contain only a low dose of iron (5mg to 60mg). The dose iron in different commercially available iron preparations varies from 5mg 1o 105mg. As you can see, it’s a bit of a minefield so make sure that you are taking a proper dose of iron when you have iron deficiency. Some women will need an Iron Infusion. During pregnancy, an Infusion is usually performed in a hospital setting. This completes the argument for treating mild deficiency early with low doses of iron – preferably pre-pregnancy.

Routine Tests in the 1st Trimester.

As part of your initial examination, a number of blood and urine tests will be performed.  It is safe to have a cervical cancer screening test and this should not be delayed until after delivery. You can expect the following tests during your first trimester:

FBC – full blood count. This is an indicator of general health and includes a count of white blood cells, red blood cells, and platelets. Anemia or infection can be detected.

Blood Group and Antibodies – This group of tests determines your blood type in case you need a transfusion at any time during your pregnancy or during or after birth. Even if you know your blood group and type from prior tests, a current test will be performed to confirm. Your blood group can be A, B, AB, or O. The Rhesus factor (Rh) factor will also be determined and it will be noted as a “+” or “-“ after the blood group; and it will be said as “positive” or “negative”   Most of the population has a positive Rh factor and you can then forget about it.

Complications can arise when the mother is Rh negative and the baby is Rh positive. Your blood will then also be checked for antibodies at 26-28 weeks.

HepBsAg – Active Hepatitis B infection (acute or chronic). Hepatitis B can be passed from mother to child. If you test positive for Hepatitis B, you will be referred for a plan of treatment to protect your baby by vaccination soon after birth and continued monitoring during the first few years of life

HIV – This viral infection can also be passed from mother to child. If you receive a positive result, you will be counselled and referred. It is not recommended that an HIV positive mother breastfeed her baby. In addition, the baby will need to be monitored and undergo testing during the first few years of life to detect any possible infection.

Rubella titre – This test determines your immunity level to rubella. You will almost certainly have been vaccinated against Rubella as a child. However, your level of immunity can change over time. This is why the test is performed with each pregnancy.

If the test shows that you are not immune, it is not safe to give you an immunization while you are pregnant – The MMR needle is given in the medical centre shortly after delivery. You will need to be especially careful to avoid situations where you might be exposed to Rubella for the first 20 weeks of your pregnancy.

Syphillis – This sexually transmitted disease is caused by a bacterial infection. Women rarely have symptoms. If your test is positive, you will be treated for the infection. It is important that you receive the proper treatment for this disease. It can cause miscarriage or preterm birth. Babies born with congenital syphilis may have developmental delays.

MSU – Midstream Urine test (also called CSU) refers to the method in which the urine is collected. Your urine sample will be tested to detect infection. Bacteria in the urine does not always cause symptoms and is linked to kidney infection, low birth weight & premature delivery. Antibiotic treatment may prevent low birth weight.

Ultrasound – An “early pregnancy ultrasound” (or dating scan) can be used to confirm pregnancy, detect heart beat (after around 6 weeks), look for twins, & determine the estimated due date. A scan may also be arranged to exclude an ectopic pregnancy.