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.