Guidelines for preventive activities in general practice

Reproductive and women’s health

First antenatal visit

      1. First antenatal visit

Reproductive and women's health​ | First antenatal visit

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Where possible, pregnant women should have their first antenatal visit within the first 10 weeks of pregnancy.1 Regular antenatal care that commences in the first trimester in pregnancy has been associated with better maternal health, fewer interventions in late pregnancy, and positive child health outcomes.1–3

Most Australian women (79%) have antenatal care in their first trimester.2 Mothers less likely to have an antenatal visit in their first trimester include women with four or more children, women aged <20 years, and women who smoke during pregnancy, use illicit substances or who live in remote and very remote areas.2

Screening

Recommendation Grade How often References
With consent, undertake the following blood tests:
  • full blood count to look for anaemia and haemoglobin disorders
  • check blood group and antibodies
  • hepatitis B virus, as effective postnatal intervention can reduce the risk of mother-to-child transmission
  • hepatitis C
  • human immunodeficiency virus (HIV), as effective interventions are available to reduce the risk of mother-to-child transmission
  • syphilis
Recommended (strong) At the first antenatal visit. 1
  • rubella immunity to identify women at risk of contracting rubella and enable postnatal vaccination to protect future pregnancies.
Conditionally recommended
With consent, test for:
  • asymptomatic bacteriuria using urine culture testing wherever possible (as it is the most accurate means of detecting asymptomatic bacteriuria early in pregnancy) as treatment is effective and reduces the risk of pyelonephritis,
Recommended (strong) At the first antenatal visit 1,4,5
  • proteinuria
Practice point
  • chlamydia in pregnant women aged <30 years, using urine samples or self-collected vaginal samples.
All pregnant women (ie regardless of age, ethnicity, family history) should be provided with information about prenatal screening tests for chromosomal conditions such as Down syndrome and for autosomal and X-linked conditions. Screening options should be discussed in the first trimester whenever possible.  
Assess/screen all women at the first antenatal visit for:
  • depression, using the Edinburgh Postnatal Depression Scale (EPDS), as early as practical in pregnancy and repeat at least once later in pregnancy
  • smoking status and exposure to passive smoking, and give the patient and her partner information about the risks to the unborn baby associated with maternal and passive smoking. If the patient smokes, emphasise the benefits of quitting as early as possible in the pregnancy and discuss any concerns she or her family may have about stopping smoking
  • intimate partner violence – 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
Recommended (strong) At the first antenatal visit (repeat screening for depression at least once later in pregnancy; consider screening for intimate partner violence more than once) 1
  • blood pressure to identify existing high blood pressure
  • clinical risk factors for pre-eclampsia
    • a history of pre-eclampsia
    • chronic hypertension
    • pre-existing diabetes
    • autoimmune disease, such as systemic lupus erythematosus
    • antiphospholipid syndrome
    • nulliparity
    • BMI >30
    • pre-existing kidney disease.
(Note: for pregnant women who are unsure of their conception date, offer an ultrasound scan to determine gestational age, detect multiple pregnancies and accurately time fetal anomaly testing.)
Conditionally recommended At the first antenatal visit. 1
  • alcohol use – provide advice not to consume alcohol during pregnancy, or around the time of conception, to prevent potential harm to the developing baby
  • use of illicit substances and misuse of pharmaceuticals, and offer advice and support regarding cessation
  • current medication – review for potential for teratogenicity in women and their partners, including prescribed and over-the-counter medication and vitamins and other supplements. Switch to and stabilise on safe pregnancy alternatives where required
  • risk of hyperglycaemia, including patient’s:
    • age
    • body mass index (BMI)
    • previous gestational diabetes or high birth weight baby
    • family history of diabetes
    • presence of polycystic ovarian syndrome and whether she is from an ethnic group with high prevalence of diabetes, such as Aboriginal and Torres Strait Islander peoples
  • problems with previous pregnancies, such as:
    • infant death
    • fetal loss
    • birth defects (particularly neural tube defects)
    • low birth weight
    • preterm birth
    • gestational diabetes and any ongoing risks that could lead to a recurrence in this pregnancy or future pregnancies
  • risk of nutritional deficiencies (eg vegan diet, lactose intolerance, and calcium, iron or vitamin D deficiency due to lack of sun exposure)
  • with consent, weight and height – calculate BMI and give patient advice about the benefits of meeting the recommended healthy weight gain during pregnancy. Please refer to the Australian Pregnancy care guidelines, Table D3: IOM recommendations for weight gain in pregnancy for calculations for recommended weight gain according to individual pre-pregnancy BMI.
Practice point At the first antenatal visit. 1

Case Finding

Recommendation Grade How often References
Ferritin testing and haemoglobin electrophoresis
In high-risk populations (refer to Specific populations), consider offering ferritin testing and haemoglobin electrophoresis.
Practice point At the first antenatal visit. 1
Proteinuria
Test for proteinuria at each antenatal visit in women with risk factors, or clinical indications of pre-eclampsia, in particular raised blood pressure.
Practice point At each antenatal visit. 1
Thyroid
At first antenatal visit, assess for risk of thyroid disease (refer to Box 1) and undertake thyroid-stimulating hormone test if risk is present.
Practice point At first antenatal visit. 1

Preventive activities and advice

For up-to-date immunisation recommendations during pregnancy, including COVID, influenza and pertussis, please refer to 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:
Folic acid supplementation
Recommend dietary supplementation of 400 µg per day folic acid, ideally from 1 month before conception and throughout the first 3 months of pregnancy to reduce the risk of neural tube defects. Where there is an increased risk of neural tube defect (anti-convulsant medication, pre-pregnancy diabetes mellitus, previous child or family history of neural tube defects, BMI >30), a 5 mg daily dose should be used.
Calcium supplementation
Advise women at high risk of developing or pre-eclampsia that calcium supplementation (at least 1000 mg daily) is beneficial if dietary intake is low.
Recommended (strong) N/A 1,6
Calcium supplementation
Advise pregnant women at risk of hypertension to take a calcium supplement (at least 1000 mg daily).
Conditionally recommended N/A
Iodine supplementation
Consider iodine supplementation 150 μg per day throughout pregnancy* as requirements increase during pregnancy.
Practice point N/A
Vitamin A, C and E supplementation
Do not take high-dose supplements of vitamin 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
Exercise, nutrition and weight management:

Aerobic and strength conditioning exercise
Advise pregnant women without contraindications that they should participate in regular aerobic and strength conditioning exercise during pregnancy. Exercise prescription for the pregnant woman requires appropriate consideration of the frequency, intensity, duration and mode of exercise; and that exercise prescription should consider the patient’s baseline fitness level.
Pelvic floor exercises
All pregnant women are advised to do pelvic floor exercises during and after pregnancy.
Conditionally recommended N/A 7,8
Nutrition and weight management
Advise on the benefits of a healthy diet and regular physical activity in preventing adverse outcomes, including excessive weight gain.  Discuss weight management and caution against being overweight or underweight. Recommend regular, moderate-intensity exercise.
Practice point N/A 1
Other preventive advice:
 
Oral health
Advise women to have oral health checks and treatment, if required, as good oral health is important to a patient’s health and treatment can be safely provided during pregnancy.
 
Low-dose aspirin
Advise women at moderate–high risk of pre-eclampsia that low-dose aspirin from early pregnancy may be of benefit in its prevention. Where appropriate, commence low-dose aspirin.
Conditionally recommended N/A 1
*Except for women with Grave’s disease

The following has been adapted from the Australian Pregnancy care guidelines, 5.2 Antenatal visits.

The first antenatal visit provides an opportunity to undertake important screening tests, vaccinations and preventive activities. It is also an opportunity to discuss the patient’s wishes and plans and any factors that may affect the pregnancy or birth. Given the volume of important screening, preventive activities and information that needs to be conveyed, the first antenatal visit should be longer than later antenatal visits.1 Another appointment can be arranged to cover other ‘first visit’ activities if there is insufficient time at the first consultation.1

Provide patient-centred care

The first antenatal visit provides an opportunity to discuss patient expectations and preferences for ongoing antenatal care and options for birth. GPs should also provide information and advice (verbally, written, or other) on diet, exercise and local pregnancy care services, and discuss the recommended tests and screens.

Ideally, the patient should be seen alone during the first antenatal visit (or at least once during pregnancy) to provide an opportunity to disclose possible domestic violence, discuss the involvement of their partner and/or family, and other aspects of the patient’s personal history.1

Health professionals should support women to take an active role in shared decision making about their physical activity/exercise during and after pregnancy. All health professionals who provide care during pregnancy should be familiar with contraindications, signs and symptoms that suggest physical activity/exercise should be modified or avoided.1 

Undertake a comprehensive history

A comprehensive history should include:1

  • current pregnancy (planned, unplanned, wishes to proceed with or terminate the pregnancy)
  • medical (history, medicines, family history [high blood pressure, diabetes, genetic conditions], cervical smears, immunisation, breast surgery),
  • obstetric (previous experience of pregnancy and birth)
  • infant feeding experiences
  • nutrition and physical activity
  • smoking, alcohol and other substance misuse
  • expectations, partner/family involvement, cultural and spiritual issues, concerns, knowledge, pregnancy, birth, breastfeeding and infant feeding options
  • factors that may affect the pregnancy or birth (eg female genital mutilation/cutting)
  • psychosocial factors affecting the patient’s emotional health and wellbeing
  • the patient’s support networks and information needs.

Provide a clinical assessment1

  • Discuss conception and date of last menstrual period, and offer ultrasound scan for gestational age assessment (carried out between 8 and 14 weeks of pregnancy).
  • Measure height and weight and calculate BMI and provide advice on appropriate weight gain.
  • Measure blood pressure.
  • Test for proteinuria.
  • Delay auscultation of fetal heart until after 12 weeks’ gestation if using a Doppler and 28 weeks’ gestation if using Doppler or a Pinard stethoscope.
  • Assess risk of pre-eclampsia and advise women at risk that low-dose aspirin from early pregnancy may be helpful in its prevention,
  • Assess risk of preterm birth and provide advice on risk and protective factors.
  • Administer the Edinburgh Postnatal Depression Scale (EPDS) at this visit or as early as practical in pregnancy.
  • Ask questions about psychosocial factors that affect mental health.

Undertake maternal health testing

Maternal health testing should be undertaken as per recommendations above.

Undertake an assessment

Assessment should include estimated date of birth/gestational age, any physical, social or emotional risk factors, need for referrals, investigations, treatments or preventive care.

Further advice and actions

Provide:

  • advice on options for antenatal care and place of birth
  • general advice (also for the partner/family), including pregnancy symptoms
  • if required, access to counselling and termination.

Structured exercise interventions

Advise women that structured lifestyle interventions improve maternal and infant outcomes and are effective in preventing excessive weight gain (treadmill, stationary cycling, walking, dance, circuit training, swimming), and recommend muscle strengthening exercises (including pelvic floor exercises) for around 60 minutes, three times a week at an intensity of 60–80% of maximum heart rate or 12–14 on the Borg scale and continued to 36–39 weeks of pregnancy.1

Pelvic floor

Pelvic floor muscle exercises appear to reduce the risk of urinary incontinence in late pregnancy (odds ratio [OR] 0.38; 95% confidence interval [CI]: 0.20, 0.72; six studies; n = 624; low quality) and at 3–6 months postpartum (OR 0.71; 95% CI: 0.54, 0.95; five studies; n = 673; moderate quality) but do not appear to affect the risk of faecal incontinence (OR 0.61; 95% CI: 0.30, 1.25; two studies; n = 867; moderate quality).1

Foods to be consumed with caution during pregnancy

  • Due to the risk of listeriosis, pre-prepared or pre-packaged cut fruit or vegetables should be cooked. Pre-prepared salad vegetables (eg from salad bars, including fruit salads and cut melon) should be avoided.
  • Raw or undercooked meat, chilled pre-cooked meats, and pâté and meat spreads should be avoided during pregnancy due to risk of listeriosis.
  • Care needs to be taken with consumption of some fish species (eg shark/flake, marlin or broadbill/swordfish, orange roughy and catfish) due to the potentially higher mercury content.
  • Foods containing raw eggs should be avoided due to the risk of salmonella.
  • Unpasteurised dairy products and soft, semi-soft and surface-ripened cheese should be avoided due to the risk of listeriosis.
  • Sugar-sweetened drinks are associated with dental conditions, such as caries.
  • Food Standards Australia and New Zealand suggests limiting intake during pregnancy to 200 mg/day of caffeine FSANZ 2019, noting that caffeine is present in coffee (145 mg/50 mL espresso; 80 mg/250 mL instant coffee), tea (50 mg/220 mL), colas (36 mg/375 mL), energy drinks (80 mg/250 mL) and chocolate (10 mg/50g).

If a patient has a low dietary calcium intake, advise her to increase her intake of calcium-rich foods.

Box 1. First antenatal visit: Identifying women at high risk of thyroid dysfunction
 
While this is an evolving area of practice, the American Thyroid Association considers women with the following to be at high risk of thyroid disease:1,9
  • history of thyroid dysfunction
  • symptoms or signs of thyroid dysfunction
  • presence of a goitre
  • known thyroid antibody positivity.
Other risk factors for thyroid disease include:1,9
  • age >30 years
  • history of type 1 diabetes or other autoimmune disorders
  • history of pregnancy loss, preterm birth or infertility
  • history of head or neck radiation or prior thyroid surgery
  • family history of autoimmune thyroid disease or thyroid dysfunction
  • BMI ≥40 kg/m2
  • use of amiodarone, lithium or recent administration of iodinated radiologic contrast
  • two or more prior pregnancies
  • residing in area of moderate to severe iodine deficiency.

It is recommended that in areas with an ongoing syphilis outbreak, pregnant women should be tested for syphilis at:1

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

Additional time may be required at the first antenatal visit for women who have:1

  • limited experience or understanding of the health system
  • limited understanding of English
  • hearing impairment requiring the use of Auslan
  • past experiences that affect their trust in authorities or health professionals
  • psychosocial circumstances that require more intensive support
  • other conditions that require additional care (below).

Groups of women who may require additional care in pregnancy include those with:1

  • existing conditions (eg overweight, underweight, cardiovascular disease, mental health, disability, female genital mutilation/cutting)
  • adverse experiences in previous pregnancies
  • previous major surgery (including cardiac, gastrointestinal, bariatric and gynaecological)
  • history of alcohol misuse or recreational drug use
  • psychosocial factors including developmental delay, vulnerability or lack of social support or previous experience of violence or social dislocation.

High-risk population groups for haemoglobin disorders include people from any of the following ethnic backgrounds: 1 Southern European, African, Middle Eastern, Chinese, Indian subcontinent, Central and South-east Asian, Pacific Islander, New Zealand Māori, South American, Caribbean, and some northern Western Australian and Northern Territory Aboriginal and Torres Strait Islander communities.

Information on prenatal screening and when to refer:
Prenatal screening, Genomics in general practice | 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 

Identifying, responding and supporting patients experiencing abuse and violence:
Abuse and violence: Working with our patients in general practice | 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 consists of five elements designed to reduce stillbirth rates after 28 weeks’ gestation:
Safer Baby Bundle | Stillbirth Centre of Research Excellence 

Patient brochures with advice for eating well and staying active in pregnancy:
Your Healthy Pregnancy | Department of Health and Aged Care

  1. Australian Living Evidence Collaboration. Pregnancy care guidelines. ALEC, 2020 [Accessed 14 March 2024].
  2. Australian Institute of Health and Welfare. National Core Maternity Indicators. Cat. no. PER 95. AIHW, 2022 [Accessed 17 May 2023].
  3. Australian Institute of Health and Welfare. Australia's mothers and babies. Cat. no. PER 101. AIHW, 2022 [accessed 17 May 2023].
  4. The Royal Australian College of General Practitioners. Abuse and violence: Working with our patients in general practice (White Book). 5th edn. RACGP, 2021.
  5. The Royal Australian College of General Practitioners. Genomics in general practice. RACGP, 2022.
  6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Vitamin and mineral supplementation and pregnancy. RANZCOG, 2019 [Accessed 14 March 2024].
  7. Brown WJ, Hayman M, Haakstad LAH,. Evidence-based physical activity guidelines for pregnant women: Report for the Australian Government Department of Health, March 2020. Australian Government, Department of Health, 2020 [Accessed 14 March 2024].
  8. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Exercise during pregnancy. RANZCOG, 2020 [Accessed 14 March 2024].
  9. Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid 2017;27(3):315–389. doi: 10.1089/thy.2016.0457. Erratum in: Thyroid 2017;27(9):1212.
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