Organisation of antenatal care
Looking after pregnant women presents one of the paradoxes of modern medicine. Normal women proceeding through an uneventful pregnancy require little formal medicine. Conversely, those at high risk of damage to their own health or that of their fetus require the use of appropriate scientific technology. Accordingly, there are two classes of women, the larger group requiring support but not much intervention and the other needing the full range of diagnostic and therapeutic measures as in any other branch of medicine. To distinguish between the two is the aim of a well run antenatal service. Antenatal clinics provide a multiphasic screening service; the earlier women are screened to identify those at high risk of specified problems the sooner appropriate diagnostic tests can be used to assess such women and their fetuses and treatment can be started. As always in medicine, diagnosis must precede treatment, for unless the women who require treatment can be identified specifically, management cannot be correctly applied.
Background
Some women attend for antenatal care because it is expected of them. They have been brought up to believe that antenatal care is the best way of looking after themselves and their unborn children. This is reinforced in all educational sources from medical textbooks to women’s magazines. Prenatal care started in Edinburgh at the turn of the 20th century, but clinics for the checking of apparently well pregnant women were rare before the first world war. During the 1920s a few midwifery departments of hospitals and interested general practitioners saw women at intervals to check their urine for protein. Some palpated the abdomen, but most pregnant women had only a medical or midwifery consultation once before labour, when they booked. Otherwise, doctors were concerned with antenatal care only “if any of the complications of pregnancy should be noticed”. Obstetrics and midwifery were first aid services concerned with labour and its complications: virtually all vigilance, thought, and attention centred on delivery and its mechanical enhancement. Little attention was paid to the antenatal months. During the 1920s a wider recognition emerged of the maternal problems of pregnancy as well as those of labour; the medical profession and the then Ministry of Health woke up to realise that events of labour had their precursors in pregnancy. Janet Campbell, one of the most farsighted and clear thinking women in medicine, started a national system of antenatal
clinics with a uniform pattern of visits and procedures; her pattern of management can still be recognised today in all the clinics of the Western world. Campbell’s ideas became the clinical obstetric screening service of the 1930s. To it has been added a series of tests, often with more enthusiasm than scientific justification; over the years few investigations have been taken away, merely more added. Catalysed by the National Perinatal Epidemiological Unit in Oxford, various groups of more thoughtful obstetricians have tried to sort out which of the tests are in fact useful in predicting fetal and maternal hazards and which have a low return for effort. When this has been done a rational antenatal service may be developed, but until then we must work with a confused service that “growed like Topsy”. It is a mixture of the traditional clinical laying on of hands and a
Some women attend for antenatal care because it is expected of them. They have been brought up to believe that antenatal care is the best way of looking after themselves and their unborn children. This is reinforced in all educational sources from medical textbooks to women’s magazines. Prenatal care started in Edinburgh at the turn of the 20th century, but clinics for the checking of apparently well pregnant women were rare before the first world war. During the 1920s a few midwifery departments of hospitals and interested general practitioners saw women at intervals to check their urine for protein. Some palpated the abdomen, but most pregnant women had only a medical or midwifery consultation once before labour, when they booked. Otherwise, doctors were concerned with antenatal care only “if any of the complications of pregnancy should be noticed”. Obstetrics and midwifery were first aid services concerned with labour and its complications: virtually all vigilance, thought, and attention centred on delivery and its mechanical enhancement. Little attention was paid to the antenatal months. During the 1920s a wider recognition emerged of the maternal problems of pregnancy as well as those of labour; the medical profession and the then Ministry of Health woke up to realise that events of labour had their precursors in pregnancy. Janet Campbell, one of the most farsighted and clear thinking women in medicine, started a national system of antenatal
clinics with a uniform pattern of visits and procedures; her pattern of management can still be recognised today in all the clinics of the Western world. Campbell’s ideas became the clinical obstetric screening service of the 1930s. To it has been added a series of tests, often with more enthusiasm than scientific justification; over the years few investigations have been taken away, merely more added. Catalysed by the National Perinatal Epidemiological Unit in Oxford, various groups of more thoughtful obstetricians have tried to sort out which of the tests are in fact useful in predicting fetal and maternal hazards and which have a low return for effort. When this has been done a rational antenatal service may be developed, but until then we must work with a confused service that “growed like Topsy”. It is a mixture of the traditional clinical laying on of hands and a
patchily applied provision of complex tests, whose availability often depends as much on the whims of a health authority’s ideas of financial priority as on the needs of the women and their fetuses. As well as these economic considerations, doctors planning the care of women in pregnancy should consider the women’s own wishes. Too often antenatal clinics in the past have been designated cattle markets; the wishes of women coming for care should be sought and paid attention to. A recurrent problem is the apparent rush of the hospital clinic. The waiting time is a source of harassment and so is the time taken to travel to the clinic. Most women want time and a rapport with the antenatal doctor or midwife to ask questions and have them answered in a fashion they can understand. It is here that the midwives
come into their own for they are excellent at the care of women undergoing normal pregnancies. In many parts of the country midwives run their own clinics in places where women would go as part of daily life. Here,
midwives see a group of healthy normal women through pregnancy with one visit only to the hospital antenatal clinic.To get the best results, women at higher risk need to be screened out at or soon after booking. They will receive intensive care at the hospital consultant’s clinic and those at intermediate risk have shared care between the general practitioner and the hospital. The women at lower risk are seen by the midwives at the community clinics. Programmes of this nature now run but depend on laying down protocols for care agreed by all the obstetricians, general practitioners and midwives. Co-operation and agreement between the three groups of carers, with mutual respect and acceptance of each other’s roles, are essential. Janet Campbell started something in 1920. We should not necessarily think that the pattern she derived is fixed forever, and in the new century we may start to get it right for the current generation of women.
come into their own for they are excellent at the care of women undergoing normal pregnancies. In many parts of the country midwives run their own clinics in places where women would go as part of daily life. Here,
midwives see a group of healthy normal women through pregnancy with one visit only to the hospital antenatal clinic.To get the best results, women at higher risk need to be screened out at or soon after booking. They will receive intensive care at the hospital consultant’s clinic and those at intermediate risk have shared care between the general practitioner and the hospital. The women at lower risk are seen by the midwives at the community clinics. Programmes of this nature now run but depend on laying down protocols for care agreed by all the obstetricians, general practitioners and midwives. Co-operation and agreement between the three groups of carers, with mutual respect and acceptance of each other’s roles, are essential. Janet Campbell started something in 1920. We should not necessarily think that the pattern she derived is fixed forever, and in the new century we may start to get it right for the current generation of women.
Styles of antenatal care
The type of antenatal care that a woman and her general practitioner plan will vary with local arrangements. The important first decision on which antenatal care depends is where the baby will be delivered. Ninety seven per cent of babies in the UK are now delivered in institutions, a third of the 2.2% of domiciliary deliveries are unplanned, so about 1.5% are booked as home deliveries. If the delivery is to be in an institution there is still the choice in some areas of general practitioner deliveries either at a separate unit run by general
practitioners isolated from the hospital or in a combined unit with a consultant. Most deliveries take place in an NHS hospital under the care of a consultant team. A small but possibly increasing number in the next few years may be delivered in private care, by a general practitioner obstetrician, a consultant obstetrician, or an independent midwife. Recently a series of midwife led delivery units have been established with no residential medical cover. Once the plans for delivery are decided, the pattern of antenatal visits can be worked out. If general practitioners or midwives are going to look after delivery, antenatal care might be entirely in their hands, with the use of the local obstetric unit for investigations and consultation. At the other end of the
spectrum, antenatal care is in the hands of the hospital unit under a consultant obstetrician and a team of doctors and midwives, the general practitioner seeing little of the woman until she has been discharged from hospital after delivery. Most women, however, elect for antenatal care between these two extremes. They often wish to take a bigger part in their own care. In some antenatal clinics the dipstick test for proteinuria is done by the woman herself. As well as providing some satisfaction, this reduces the load and waiting time at the formal antenatal visit. During pregnancy there may be visits, at certain agreed stages of gestation, to the hospital antenatal clinic for crucial checks, and for the rest of the time antenatal care is performed in the general practitioner’s surgery or midwives’ clinic. These patterns of care keep the practitioner involved in the obstetric care of the woman and allow the woman to be seen in slightly more familiar surroundings and more swiftly. In some areas clinics outside the hospital are run by community midwives; these are becoming increasingly popular. Home antenatal care visits also take place, including the initial booking visit. Delivery may be in the hospital by the consultant led team, by a general practitioner obstetrician, or by a midwife. It is wise, with the introduction of Crown indemnity, that all general practitioner obstetricians have honorary contracts with the hospital obstetric department that they attend to supervise or perform deliveries. About 2% of women now have a home delivery. More than half of these are planned and for this group, antenatal care may well be midwifery led (see ABC of Labour Care).
spectrum, antenatal care is in the hands of the hospital unit under a consultant obstetrician and a team of doctors and midwives, the general practitioner seeing little of the woman until she has been discharged from hospital after delivery. Most women, however, elect for antenatal care between these two extremes. They often wish to take a bigger part in their own care. In some antenatal clinics the dipstick test for proteinuria is done by the woman herself. As well as providing some satisfaction, this reduces the load and waiting time at the formal antenatal visit. During pregnancy there may be visits, at certain agreed stages of gestation, to the hospital antenatal clinic for crucial checks, and for the rest of the time antenatal care is performed in the general practitioner’s surgery or midwives’ clinic. These patterns of care keep the practitioner involved in the obstetric care of the woman and allow the woman to be seen in slightly more familiar surroundings and more swiftly. In some areas clinics outside the hospital are run by community midwives; these are becoming increasingly popular. Home antenatal care visits also take place, including the initial booking visit. Delivery may be in the hospital by the consultant led team, by a general practitioner obstetrician, or by a midwife. It is wise, with the introduction of Crown indemnity, that all general practitioner obstetricians have honorary contracts with the hospital obstetric department that they attend to supervise or perform deliveries. About 2% of women now have a home delivery. More than half of these are planned and for this group, antenatal care may well be midwifery led (see ABC of Labour Care).
Early diagnosis of pregnancy
When a woman attends a practitioner thinking that she is pregnant, the most common symptoms are not always amenorrhoea followed by nausea. Many women, particularly the multiparous, have a subtle sensation that they are pregnant a lot earlier than the arrival of the more formal symptoms and signs laid down in textbooks. Traditionally, the doctor may elicit clinical features, but most now turn to a pregnancy test at the first hint of pregnancy. Symptoms The symptoms of early pregnancy are nausea, increased sensitivity of the breasts and nipples, increased frequency of micturition, and amenorrhoea.
Signs
The doctor may notice on examination a fullness of the breasts with early changes in pigmentation and Montgomery’s tubercuiles in the areola. The uterus will not be felt through the abdominal wall until about 12 weeks of pregnancy. On bimanual assessment uterine enlargement is detectable before this time while cervical softening and a cystic, generally soft feeling of the uterus can be detected by eight weeks. This more subtle sign is not often sought as vaginal examination is not usually performed on a normal woman at this time.
Tests
Mostly the diagnosis of pregnancy is confirmed by tests checking for the higher concentrations of human chorionic gonadotrophin that occur in every pregnancy. The old biological tests using rabbits and frogs are now gone and have been replaced by immunological tests. These depend on the presence of human chorionic gonadotrophin in the body fluids, which is reflected in the urine. The more sensitive the test, the more likely it is to pick up the hormone at lower concentrations—that is, earlier in pregnancy. Enzyme linked immunosorbent assay (ELISA) is the basis of many of the commercial kits currently available in chemist
shops. The assay depends on the double reaction of standard phase antibody with enzyme labelled antibody, which is sensitive enough to detect very low concentrations of human chorionic gonadotrophin. Positive results may be therefore detectable as early as 10 days after fertilisation—that is, four days before the first missed period. Vaginal ultrasound can detect a sac from five weeks and a fetal cardiac echo a week or so later (Chapter 4), but this would not be used as a screening pregnancy test.
Conclusion
At the end of the preliminary consultation women may ask questions about the pregnancy and the practitioner will deal with these. Most of these queries will be considered in the chapter on normal antenatal management. For most women the onset of pregnancy is a desired and happy event, but for a few it may not be so and practitioners, having established a diagnosis, may find that they are then asked to advise on termination of pregnancy. This they should do if their views on the subject allow; if not, they should arrange for one of their partners to discuss it with the patient. Most women, however, will be happy to be pregnant and looking forward to a successful outcome.
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