Guidelines for preventive activities in general practice

Reproductive and women’s health

During pregnancy

      1. During pregnancy

Reproductive and women's health | During pregnancy

Screening age bar

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In 2020 in Australia, 295,976 babies were born to 291,712 mothers.1 There has been an increase in Australia of the average age of first-time mothers (28.3 years in 2010 to 29.6 years in 2020).1 It is important that antenatal visits during pregnancy are flexible, patient-centred and planned collaboratively according to the specific needs and wishes of the patient.2 Each antenatal visit provides an opportunity to ask the patient about any issues or concerns they have, including any psychosocial support and mental health issues.2 GPs should also offer information and education in preparation of labour and breastfeeding.

Screening

For recommendations on cell-free DNA (cfDNA)-based screening (also called Non-invasive prenatal testing (NIPT) and carrier screening, see Genetics.
For recommendations on screening for depression – see Depression and Perinatal mental health.
 
Recommendation Grade How often References
Undertake the following blood tests:
  • fasting plasma glucose or plasma glucose 1 hour and 2 hours after 75 g glucose loading (glucose tolerance test) for testing for gestational diabetes (Note: glycated haemoglobin (HbA1c) is not recommended as a test for gestational diabetes due to a lack of sensitivity.)
Practice point Between 24–28 weeks’ gestation 2,3
  • Haemoglobin concentration (full blood count)
At 28 weeks’ gestation 2
  • Consider an antibody screen at 28 weeks in those that are rhesus (Rh D) negative.
4
Repeat testing for syphilis is recommended for women at high risk of infection or reinfection.* Recommended (strong) At 28–32 weeks’ gestation and at the time of birth 2
Alcohol and substance use
Asking about substance use at subsequent visits is important as some women are more likely to report sensitive information only after a trusting relationship has been established.
 
Practice point Every antenatal visit. 2
Intimate partner violence
Routine screening for intimate partner violence is strongly recommended. Explain to all women that asking about family violence is a routine part of antenatal care. Ask about family violence only when alone with the patient, using specific questions or validated screening tools used in your state/territory.
Recommended (strong) Consider more than once. 5
Fetal development and anatomy
Ultrasound screening to assess fetal development, anatomy and cervical length at 18–20 weeks’ gestation is recommended.
Conditionally recommended At 18–20 weeks’ gestation 2,6
Weight
At every antenatal visit, offer women the opportunity to be weighed so that low or high gestational weight gain is identified, and risk of associated adverse outcomes monitored. Obesity is a major risk factor for poor maternal and fetal outcomes.
Practice point Every antenatal visit. 1,2
Blood pressure
Routinely measure blood pressure to identify new onset hypertension.
Practice point At every antenatal visit. 1,2
Fundal height
At each antenatal visit from 24 weeks, measure fundal height in centimetres.
Practice point At every antenatal visit from 24 weeks. 2
*Due to changing disease patterns, please consult local guidelines.

Case finding

Recommendation Grade How often References
Proteinuria
In women with risk factors for or clinical indications of pre-eclampsia – in particular, raised blood pressure – test for proteinuria at each antenatal visit.
Practice point Every antenatal visit. 2

Preventive activities and advice

For up-to-date immunisation recommendations in pregnancy, including COVID, influenza and pertussis, please refer to the Australian immunisation handbook – Vaccination for women who are planning pregnancy, pregnant or breastfeeding and Immunisation recommendations for non-Indigenous Australians without risk factors for vaccine-preventable diseases.
Recommendation Grade How often References
Supplementation
  • Vitamin A, C and E supplementation: Do not take high-dose supplements of vitamins A, C or E as they are of no benefit in pregnancy, and in the absence of an identified deficiency, may cause harm.
Not recommended (strong) N/A 2
  • Omega-3: Supplementation with omega-3 long-chain polyunsaturated fatty acids (800 mg docosahexaenoic acid [DHA] and 100 mg eicosapentaenoic acid [EPA] per day) may reduce their risk of preterm birth, if they are low in omega-3 (omega-3 fatty acids are found predominantly in oily fish such as mackerel, herrings, sardines, salmon and tuna).*
Conditionally recommended N/A 2
  • Iodine: Suggest that pregnant women take an iodine supplement of 150 µg each day. Women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking an iodine supplement.
Practice point N/A 2
  • Calcium: Advise women at high risk of developing pre-eclampsia that calcium supplementation is beneficial if dietary intake is low. Refer to Box 1. Refer to Box 1.
Recommended (strong) N/A 2
Nutrition and exercise
  • Nutrition: Advise women that healthy dietary patterns are characterised by high intake of fruits, vegetables, legumes, wholegrains, fish, seafood, unprocessed meats, dairy foods and water. Diets with high intake of sweetened foods and drinks, foods high in saturated fats (eg fried foods), processed meats and refined grains are associated with poorer outcomes.
Practice point N/A 2
  • Physical activity: Regular aerobic and strength conditioning exercise is recommended for pregnant women without contraindications.
Conditionally recommended N/A 7,8
  • Pelvic floor exercises: All pregnant women are advised to do pelvic floor exercises during and after pregnancy.
Practice point N/A  
Other preventive activities and advice
  • Medications: Advise women that use of prescription and over-the-counter medicines should be limited to circumstances where the benefit outweighs the risk as few medicines have been established as safe to use in pregnancy. Cessation should be in consultation.
Practice point N/A 2
  • Low-dose aspirin: Low-dose aspirin (50–150 mg) is recommended for women of moderate to high risk of developing pre-eclampsia. Refer to the Australian Pregnancy care guidelines – Identifying women with risk factors for pre-eclampsia.
  • Oral health: Advise women to have oral health checks and treatment, if required, as good oral health is important to a woman’s health and treatment can be safely provided during pregnancy.
  • Seat belts: Inform pregnant women about the correct use of seat belts; that is, three-point seat belts ‘above and below the bump, not over it’.
  • Sexual activity: Advise pregnant women without complications that safe sexual activity in pregnancy is not known to be associated with any adverse outcomes. 
Conditionally recommended N/A 2
  • Side sleeping: Advise side sleeping from 28 weeks’ pregnancy for prevention of stillbirth.
Practice point N/A 9,10

In addition to screening and preventive activities, each antenatal visit provides an opportunity to review care plan, identify women who require additional support and care, and for the patient to ask questions and discuss any issues.2

Physical activity
Reassure the patient that physical activity/exercise during pregnancy and the postpartum period is safe, has health benefits for the woman and her unborn child, and reduces the risks of some pregnancy-related complications.7,8

Healthy environments
Repeated exposure to hazardous toxins in the household and workplace environment can affect fertility and increase the risk of miscarriage and birth defects. 

  • Discuss the avoidance of TORCH infections: Toxoplasmosis, Other (eg syphilis, varicella, mumps, parvovirus and human immunodeficiency virus [HIV], listeriosis), Rubella, Cytomegalovirus and Herpes simplex.
  • Toxoplasmosis: Avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk products; wash all fruit and vegetables.
  • Cytomegalovirus, parvovirus B19 (fifth disease): Discuss the importance of frequent hand washing. Those who work with children or in the healthcare sector can further reduce risk by using gloves when changing nappies.

Nutrition
Pregnancy and lactation pose nutrition risks due to increased nutrient demands. Maternal nutritional status significantly influences the nutritional wellbeing of both the fetus and the infant.11

Refer to Further information in ‘First antenatal visit’ for information on foods to be consumed with caution during pregnancy.

Moderate/high risk of pre-eclampsia

Moderate risk of pre-eclampsia includes any of the following:12

  • nulliparity
  • age ≥40 years
  • pregnancy interval >10 years
  • body mass index (BMI) ≥35 kg/m2 at first visit
  • family history of pre-eclampsia
  • multi-fetal pregnancy.

High risk of pre-eclampsia includes any of the following:12

  • hypertensive disease during a previous pregnancy
  • chronic kidney disease
  • autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
  • type 1 or type 2 diabetes
  • chronic hypertension.

Pregnant women who live in an area affected by an ongoing syphilis outbreak should be tested at each of the following:2

  • the first antenatal visit
  • 28 weeks
  • 36 weeks
  • time of birth
  • six weeks after the birth.

The Australian Pregnancy care guidelines have a list of targeted tests to consider for women identified at increased risk.

Populations that may require extra or differing support services for pregnancy include:

  • Aboriginal and Torres Strait Islander people2,13,14
  • migrant and refugee women2
  • women with severe mental illness2
  • women aged <20 years2,14
  • women in rural and remote areas2
  • women with disability15
  • women in a low socioeconomic environment and/or experiencing homelessness16–18
  • single women16
  • LGBTIQA+ people19
 
 

Identifying, responding and supporting patients experiencing abuse and violence:
Abuse and violence – Working with our patients in general practice (White Book) | RACGP 

Information on gestational diabetes, including diagnosis, management and follow-up:
Gestational diabetes mellitus, Management of type 2 diabetes: A handbook for general practice | RACGP 

Further information on Omega-3 long chain polyunsaturated fatty acid (LCPUFA) supplementation in pregnancy:
Omega-3 fatty acid addition in pregnancy to reduce the risk of preterm birth, Handbook of non-drug interventions (HANDI) | RACGP 

Information on investigations, treatments and outcomes for nausea, vomiting, and hyperemesis gravidarium:
Guideline for the management of nausea and vomiting in pregnancy and hyperemesis gravidarium | The Society for Obstetric Medicine of Australia and New Zealand (SOMANZ) 

The Safer Baby Bundle, consisting of five elements designed to reduce stillbirth rates after 28 weeks’ gestation:
Safer Baby Bundle | Stillbirth Centre of Research Excellence 

Current advice for healthcare professionals and hospitals undertaking obstetric care with anaesthesia and analgesia services, to assist with safe and appropriate care for women during pregnancy and labour:
Joint RANZCOG/ANZCA/RACGP position statement on obstetric anaesthesia and analgesia services | Royal Australian and New Zealand College of Obstetricians and Gynaecologists and Australian and New Zealand College of Anaesthetists 

For up-to-date information on immunisation recommendations:
Vaccination for women who are planning pregnancy, pregnant or breastfeeding, The Australian immunisation handbook | Australian Government Department of Health and Aged Care 

Information about breastfeeding:
Infant feeding guidelines: Information for health workers | National Health and Medical Research Council 

Information for GPs and patients about alcohol in pregnancy:
Every moment matters | Foundation for Alcohol, Research and Education (FARE)

 
 
  1. Australian Institute of Health and Welfare. Australia's mothers and babies. Cat. no. PER 101. AIHW, 2022 [Accessed 29 May 2023].
  2. Department of Health. Clinical practice guidelines: Pregnancy care. Australian Government DoH, 2020.
  3. The Royal Australian College of General Practitioners. Management of type 2 diabetes: A handbook for general practice. RACGP, 2020.
  4. National Blood Authority. Prophylactic use of Rh D immunoglobulin in pregnancy care. NBA, 2021 [Accessed 13 May 2023].
  5. The Royal Australian College of General Practitioners. Abuse and violence: Working with our patients in general practice (White Book). 5th edn. RACGP, 2021.
  6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Measurement of cervical length for the prediction of preterm birth. RANZCOG, 2021 [Accessed 13 March 2024].
  7. Brown WJ, Hayman M, Haakstad LAH, et al. Evidence-based physical activity guidelines for pregnant women: Report for the Australian Government Department of Health. Australian Government DoH, 2020 [Accessed 14 March 2024].
  8. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Exercise during pregnancy. RANZCOG, 2020 [Accessed 13 March 2024].
  9. Stillbirth Centre of Research Excellence. The Safer Baby Bundle. South Brisbane: CRE, 2023
  10. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Common questions in pregnancy. RANZCOG, 2020. Available at: [Accessed 13 March 2024].
  11. National Health and Medical Research Council. Australian dietary guidelines. NHMRC, 2013.
  12. National Institute for Health and Care Excellence. Hypertension in pregnancy: Diagnosis and management. NICE, 2023.
  13. National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 3rd edn. RACGP, 2018.
  14. Australian Institute of Health and Welfare. Australia’s mothers and babies. AIHW, 2023 [Accessed 21 July 2023].
  15. Gleason J, Grewal J, Chen Z, Cernich AN, Grantz KL. Risk of adverse maternal outcomes in pregnant women with disabilities. JAMA Netw Open 2021;4(12):e2138414. doi: 10.1001/jamanetworkopen.2021.38414.
  16. Bedaso A, Adams J, Peng W, Sibbritt D. Prevalence and determinants of low social support during pregnancy among Australian women: A community-based cross-sectional study. Reprod Health 2021;18(1):158. doi: 10.1186/s12978-021-01210-y.
  17. St Martin B, Spiegel A, Sie L, et al. Homelessness in pregnancy: perinatal outcomes. J Perinatol 2021;41(12):2742–48. doi: 10.1038/s41372-021-01187-3.
  18. Haylett F, Murray S, Watson J, Theobald J. The extent, nature and impact of homelessness on pregnant women and their babies. Parity 2022; 35(5):10–11 [Accessed 13 March 2024].
  19. Permezel J, Arnold ASC, Thomas J, et al. Experiences in the delivery of preconception and pregnancy care for LGBTIQA+ people: A systematic review and thematic synthesis of patient and healthcare provider perspectives. Midwifery 2023;123:103712. Doi: 10.1016/j.midw.2023.103712.
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