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Who will handle my care?
a guide to antenatal care

What types of antenatal care are available to me?
The options for antenatal care in the UK vary from one region to another, and sometimes according to the hospital you choose. so it’s worth asking your doctor or midwife early on about your choices. There are four main types of care (see p.76) The most common is shared care, where you are cared for by your doctor and community midwife with visits to the hospital limited to scans or investigations. In some areas, midwifery care is offered where you are looked after by a midwife or a team of midwives, sometimes called one-to-one care or team midwifery care. Women with pre-existing medical problems, or a more complicated pregnancy, such as a multiple pregnancy, may have consultant-led care with visits to a hospital-based consultant If you opt for private care, you will be cared for by an independent midwife Appointments will be timed to suit you and scans may be with a private obstetrician. The midwife will be on call for the birth, which may be at home, in a birth centre, or at the local hospital.
How many antenatal appointments will I need?
The exact number of appointments and how often you have them depends on your individual situation Usually, if this is your first pregnancy, you will have up to 10 appointments, whereas if you have had a baby before, you should have around 7 appointments.

When will I have my first antenatal appointment?
Your first ”booking’ appointment should be between 8 and 12 weeks, depending on the midwives’ preferences in your area. This is often the first time you will meet the midwife who will be organizing, and in most cases providing most of, your care.

I’m going for my first appointment next week - what will happen there?
The purpose of your first appointment with your local midwife is for her to obtain your medical history and exchange information so that your future care during the pregnancy and birth can be planned. This is also an opportunity for you and your midwife to get to
know each other and for you to ask any questions you may have and discuss the schedule for appointments, blood tests, scans, and antenatal classes. You will also be given booklets, information leaflets, and important contact telephone numbers
Your midwife will ask you about your medical history; your family’s medical history; your partner and your partner’s family’s medical history; about any previous pregnancies you have had; and how this pregnancy has been so far Your answers to these questions will help your midwife to build up a picture of your current state of health, and will also help identify any factors that may affect your pregnancy, for example if there is a family history of pre-eclampsia (see p.89).
Your midwife will also take your blood pressure, weigh you, test your urine (see below), and listen to the baby’s heartbeat if you are 12 or more weeks pregnant. She may also take some blood tests (see opposite). These observations provide a useful baseline for future antenatal checks

Why do I have to bring a urine sample to the clinic each time?
Your midwife is looking for the presence of protein in your urine. If protein is present, this could indicate that you have a urine infection that may need a course of antibiotics After around 24 weeks of pregnancy, protein in the urine is an indication of pre-eclampsia (see p 89), a potentially serious condition that needs close monitoring.
If you have a body mass index (BMI) (see p 18) over 35, you will be offered a glucose tolerance test, also done by testing -your urine. Glucose in the urine is a sign of gestational diabetes (see p.87) If glucose is present, you may be referred for blood tests to analyse your sugar levels. If diabetes is diagnosed, you would receive care and advice accordingly.

Why are some of my appointments with my doctor and others with the midwife?
The type of antenatal care you receive can vary slightly between different areas. If your pregnancy is straightforward, your care is usually shared between your doctor and midwife, or in some areas all your appointments are with your midwife. If you feel more comfortable with your midwife, you should be able to arrange to have the majority of your appointments with her, and the same applies if you feel happier seeing your doctor. Whichever way, it is important that -you feel able to ask any questions or discuss any issues, which may be personal or sensitive

Will I have to have an internal examination at my first antenatal appointment?
It is unlikely that you will have an internal examination at your first antenatal appointment. Twenty years or so ago, when home pregnancy tests weren’t as reliable and ultrasound scans were not so accurate or widely available, an internal examination was the
best way to confirm and ‘date” a pregnancy The midwife or doctor placed two fingers into the vagina, and pressed on the lower abdomen with the other hand to judge the size of the uterus
Nowadays, there are a few instances when an internal examination may be recommended during early pregnancy. If you have an infection, such as thrush, an internal examination enables the vagina to be visualized to check for any signs of infection and for a tissue sample to be taken with a swab (like a long cotton wool bud). The swab is sent to the hospital for testing so that the appropriate treatment can be offered
If -you have vaginal bleeding, you may have an internal examination with a speculum (an instrument shaped like a duck’s bill, used for smear tests) to allow the cervix to be seen: a small erosion on the surface is a common cause of bleeding in pregnancy Although internal examinations are not enjoyable, it is important to try and relax to help the muscles of the vagina to relax and loosen, which may prevent discomfort. Many women find it helpful to breathe slowly and steadily during the examination.

I’m very small and have tiny feet - will that be a problem when I give birth?
In the past, doctors used to measure a pregnant woman’s feet to assess her likelihood of needing a Caesarean section, as small feet were thought
to indicate a narrow pelvis Although there is some truth in the fact that small feet generally indicate that a woman is small-framed and therefore likely to have a small pelvis, small women also tend to grow small babies in proportion to their pelvic size. True cephalo-pelvic disproportion (CPD), where the baby’s head is too large to fit through the pelvis and be born vaginally is relatively rare
During labour there are other factors that help you to deliver your baby. The pelvis is not a fixed structure and the hormone relaxin helps to soften the ligaments that hold the pelvic bones together to help the pelvis to stretch and accommodate the baby
Also, your baby’s head is designed to mould into shape. The skull is made up from separate bones that are able to overlap each other slightly in order to reduce the overall size of the head as it travels through the pelvis during labour This is a normal part of the birth process. Labour positions also affect the dimensions of the pelvis. For example, squatting can increase the internal measurements of the pelvis by around 30 per cent. Sitting, or lying on your back can actually reduce these measurements by restricting the natural backwards movement of the tailbone (coccyx) during birth.

My midwife is lovely but she’s always in a hurry - how can I get her to answer my questions?
This is a common problem. Antenatal clinics are often very busy, with lots of women for the midwife to see. Asa  result, most clinics allow only a 10- to 15-minute appointment for each woman – barely enough time to go through the basic physical checks However, it is important that -your questions are addressed and it may be helpful to write them down so that you remember what you want to ask. If your midwife doesn’t have time to discuss the issues during your appointment, ask her to arrange to talk to you at a mutually convenient time This could be in the form of a phone call, or another appointment at the clinic Or she may be able to direct -you to other sources of information such as books, leaflets, websites, or other healthcare professionals.
It is a crucial part of your antenatal care that you feel comfortable with your caregivers and are given the opportunity to discuss any questions you have or issues that arise, and this is recognized by the National Institute for Clinical Excellence (NICE) in their guidelines for antenatal care (see p.310).

I’m four months’ pregnant and haven’t had many appointments. Will they get more frequent?
Yes, you will find that your antenatal appointments become more frequent as the pregnancy progresses. With your first pregnancy, you can expect a total of about 10 appointments but if you have had a baby before, you may only have 7. If you develop any complications, additional appointments would be arranged according to your needs. The schedule of antenatal appointments differs slightly from area to area, but as a general rule you can expect an appointment at the following stages of pregnancy: one to two appointments by 12 weeks of pregnancy, and then appointments at 16 weeks, 25 weeks, 28 weeks, 31 weeks, 34 weeks, 36 weeks, 38 weeks, 40 weeks, and if, your baby is overdue, 41 weeks If you are expecting your second or subsequent baby and the pregnancy is straightforward, you may miss out appointments at 25 weeks, 31 weeks, and 40 weeks.

I want a home birth. Will this make a difference to my antenatal appointments?
Usually women planning a home birth will have the same type of antenatal care as any another healthy pregnant woman in regards to frequency and location of antenatal appointments Midwives in some areas may provide a home visit towards the end of
the pregnancy if a woman is planning a home birth This is helpful as it offers an opportunity to discuss the preparations for labour and birth, such as what equipment to have ready and the intended place for the actual delivery. If your midwife cannot offer a home visit to discuss the arrangements for your home birth, you should be given an opportunity to talk about it together during one of your usual antenatal appointments.

Is it OK to bring my partner with me to the antenatal appointments?
It is absolutely fine to bring your partner with you to some or all of your antenatal appointments It is a good way for him to feel involved in the pregnancy, and also gives him an opportunity to ask questions that he may have. It is a legal requirement that you are allowed paid time off work to attend antenatal appointments, but your partner does not have this right, which may pose a problem as most antenatal clinics are during the day. Another way to involve your partner in the pregnancy is to attend birth preparation classes together Classes are often held at the weekends or in the evenings to make it easier for partners to attend This gives you both a chance to find out more about labour and birth and about babycare after the birth.

When will I hear my baby’s heart beat?
Your baby’s heart starts beating around 20 days after conception, and can be seen on an ultrasound scan at about six weeks of pregnancy It is usually not until around 12 weeks of pregnancy that it is possible to hear the heartbeat with a hand-held monitor, known as a sonicaid, as it is around this time that the uterus starts to grow upwards out of the pelvis, making it easier to detect the heartbeat When the heartbeat can be heard also depends a bit on your build; if you are very slim, it is usually easier to find the baby’s heartbeat than if you are overweight

Will I have my own midwife?
Midwives realize that it is important for a woman to develop a relationship with them so that they feel supported and able to ask questions, and continuity of care is provided if possible However, how many midwives you meet in pregnancy, labour, and birth and the postnatal period depends on how services are arranged in your area Generally, the midwife linked to -your doctor’s surgery provides the majority of care. Depending on your situation and common practice in your area, you may also meet other midwives if some of your appointments are at the hospital. When -you go into labour, you are usually cared for by hospital-based midwives who you may not have met In some areas, community midwives look after women in hospital. If this is the case, you may be familiar with the midwife caring for you in labour Midwives working on a labour ward work shifts, so it is likely that you will meet more than one midwife during your labour and birth. Your postnatal care is usually carried out by community-based midwives. This may include the midwife you saw for antenatal appointments at the surgery
I’ve only just found out I’m pregnant and I must be at least four months. What should I do?
One of the first things you need to do is to contact your local maternity unit and inform them of your pregnancy Women can refer themselves, although many still approach their doctor first. If you inform your doctor, he or she will send a referral to the hospital or to a midwife to arrange a booking appointment as soon as possible. You should also review your diet (see p.50) Depending on the number of weeks of your pregnancy, you may be due a scan, which may need to be done before the booking appointment Most units offer a scan around 10-14 weeks, and a second one around 20 weeks. You will be offered a range of blood tests (see p. 117) and should be aware of their purpose before consenting Each unit may have a slightly different schedule for care. The earlier you book in the better, so that you do not miss out on any aspects of antenatal care.

Antenatal jargon
Understanding your notes
Once your midwife has compiled your notes, you will be in charge of these and will need to take them to appointments. Abbreviations will be used for much of the medical information.
• BP Blood pressure.
• Hb Haemoglobin levels.
• Primagravida A first pregnancy
• Multigravida A subsequent pregnancy
• NAD Nothing abnormal detected (usually referring to urine sample).
FHHR Fetal heart heard and regular.
FHNH Fetal heart not heard.
FMF Fetal movements felt.
EDD Estimated date of delivery
iIc Ceph or Vx Baby head down
Br Baby is breech - feet down.
Eng/E Baby’s head is engaged for delivery * NE Baby’s head is not engaged.
* SFH Symphysis fundal height, size of the womb

Rhesus negative
Each person’s blood carries a Rhesus factor (Rh-factor), which is positive or negative Problems arise if a Rh-negative woman carries a Rh-positive baby who has inherited the status from the father. If the mother’s blood comes into contact with the baby’s blood during delivery, she may produce antibodies against the baby This does not usually affect a first baby. but may cause problems in subsequent pregnancies when a mother’s antibodies attack the cells of another Rh-positive baby
Preparing for visits
Getting ready for your antenatal appointments
Knowing what to expect at your antenatal appointments and having the necessary information to hand for the midwife will mean the allotted time is used efficiently.
At your first antenatal appointment, your midwife is gathering as much information about you as possible to build up a picture of your health and consider the most appropriate type of care for you. Make sure you have the date of your last menstrual period, as well as the dates of any previous pregnancies, including ones that ended in miscarriage You will also need to be clued up on your family’s medical history and your partner’s medical history, including any inherited abnormalities, so check before the appointment if you are unsure about anything Read any information sent by the hospital and make a list of any questions so that you don’t forget them.
Antenatal care options
Wno provides your care
The options for antenatal care in the UK vary from area to area, so this section will provide a general overview You will find out more when you go for your booking-in appointment, usually around 8-12 weeks Midwives are specialists in providing maternity care where there are no complications and they provide the majority of antenatal care to women. As they are specially trained to look after normal births, women should only have to see a doctor if a problem arises, or if they are at a higher risk of complications. Within the NHS there are three main types of care: shared care, midwifery care and consultant-led care. The Association for Improvements in Maternity Services (AIMS), has a useful website that provides plenty of support, advice, and information on maternity choices in the UK (see p. 310)
What is shared care? Most women have their antenatal appointments with their doctor or community midwife during pregnancy, with visits to the hospital only for routine scans or for investigating problems. Care is then transferred to the hospital midwives and obstetrician, if required, for the birth and postnatal stay
How does midwifery care work? In some areas, teams of community midwives provide continuous care throughout pregnancy, birth, and the postnatal period, and when this type of care
is available it tends to be a popular choice in low-risk pregnancies as it enables women to build up a relationship with their midwives The community midwives are responsible for your antenatal care, your care in hospital during the labour and birth, and then for home visits after the delivery. It is not guaranteed that you will have the same midwife all the way through your pregnancy and birth. For this reason, it’s a good idea to request antenatal appointments with different midwives within the team, so that you meet as many members of the team as possible during your pregnancy, and it will therefore be more likely that you will know the midwife who is with you for the actual labour and delivery of your baby,
When might you have consultant-led care? Women with pre-existing medical conditions, such as hypertension, or those with more complex pregnancy issues, such as twins or multiple births, may have the majority of antenatal care with an obstetrician. Most of their appointments may be carried out in hospital There are other conditions, such as diabetes or epilepsy, which may require the care of two specialists: an expert in the medical condition as well as an obstetrician. A hospital midwife will usually participate in this care too.
What about independent midwives? Outside the NHS, there is also the option of independent midwives Independent midwives are midwives who have chosen to work in the private healthcare sector. They charge a fee to provide antenatal care, care during labour and the delivery, and postnatal care Because they only look after small numbers of women, independent midwives can provide a continuity of care that is not always available on the NHS and they will also tailor care to suit your individual needs, for example timing antenatal appointments when most convenient for you You can find out more details by visiting the wesbite of the Independent Midwives Association (see p.310)
Does my care change if I’m having a home birth? As well as hospital delivery in a birthing or delivery unit, there is also the option of having a home birth within the NHS framework (see p 153). When a pregnancy is straightforward, research hasn’t found any difference in the safety of having a baby at home or in
hospital If you are having a home birth, your antenatal care will be provided by community midwives who are attached to a maternity unit. Once in labour, your midwife will stay with you until your baby is born, and she will visit regularly for between 10 and 28 days after your baby has been born, or you can attend a postnatal drop-in centre in your local area.
How will I choose my antenatal care? This may be partly dictated by the type of care that is available in your area. It’s worth talking to other local mothers with young children to see if they have any advice or recommendations. The type of care you receive may also depend on where you choose to give birth. If you have a low-risk pregnancy and decide to have a homebirth or to deliver in a birthing unit, then you will probably just see midwives and your doctor in your own home or the doctor’s surgery If there are complications, your care may be shared between your midwives and doctor and a hospital obstetrician.
Blood tests
How these contribute to your antenatal care
You will be offered quite a few blood tests during pregnancy and the results provide vital information that may affect your pregnancy and help your caregivers to plan your care. At your hooking appointment, you will be offered blood tests to check for the following:
• Anaemia (low iron levels).
• Your blood group
• Your Rhesus status (see p 79).
• Hepatitis B.
• Your rubella (German measles) immunity.
• HIV and syphilis
These are usually taken at the same time, so you won’t need a separate test for each!

How will I know I’m pregnant? FAQs.

I think I might be pregnant -what is the best way for me to confirm this?

By far the most accurate way to confirm a pregnancy is to perform a home pregnancy test. If used correctly, these are extremely accurate. Your doctor can offer a pregnancy testing service if confirmation is required This may be the case if, for example, you test too early and get a false negative result (see below) and then lose faith in the home test Apart from a home pregnancy test, pregnancy can also be confirmed with a blood test, although this is usually only done if there are possible problems such as irregular bleeding. Occasionally, ultrasound scans are used to confirm a pregnancy particularly if there is a question mark about the dates, although an embryo cannot be seen on a scan until at least four weeks after conception.

I feel pregnant - how early can I do a test?

Pregnancy tests determine if you are pregnant by detecting a hormone called human chorionic gonadotrophin (hCC) in your urine. This pregnancy hormone is released when the fertilized egg is implanted in the lining of the womb and it rises significantly in the early stages of pregnancy.Most pregnancy tests can now detect hCG as early as the day you are due to have your period. If you have irregular cycles, use your longest recent cycle to determine when you should test

My period is late but the pregnancy test was negative. Could I be pregnant?

If your test was negative and you still think you may be pregnant, wait for three days and perform another test! there may not have been enough hCG in your urine when the first test was carried out. If you have had two or three negative tests and still feel you may be pregnant, or your period has not arrived, ask your doctor for advice as there may be a number of medical reasons apart from pregnancy why your period has not arrived.

Are home pregnancy tests reliable?

If you follow the instructions carefully, home pregnancy tests are around 97-99 per cent accurate. When you are carrying out a home pregnancy test, it is advisable to use the first urine sample of the day and to not drink too much fluid the night before This is to prevent the sample becoming too diluted, which could make it difficult to measure the levels of hCG. Certain fertility medications can interfere with the results of a pregnancy test, so if you have been undergoing any fertility treatment and think this may apply to you, you should ask your doctor or fertility clinic for more information and advice. Doing a pregnancy test too early in pregnancy can produce a false negative result, which means that the test reads negative but you are really pregnant. If you think this may be the case, repeat the test in three days’ time.

I’m on the Pill but my doctor has confirmed I’m pregnant.
How can this have happened?
The oral contraceptive Pill is around 92-99.7 per cent effective, depending on the brand and how reliably it is taken. Although figures indicate that approximately 8 out of 100 women do become pregnant during the first -year of using the Pill, other studies indicate that
when the Pill is taken properly as instructed this figure falls to less than I out of 100
Ideally, the Pill should be taken at the same time each day although some types can be taken up to 12 hours late. If you forget to take even one Pill, you increase your chances of getting pregnant. If two or more Pills from the same packet are missed, this can dramatically increase the risk of pregnancy if no other contraception is being used.
Certain drugs, such as antibiotics, some herbal remedies, and other medicines can interfere with the reliability of the Pill Also, sickness and diarrhoea can reduce the Pill’s effectiveness. Talk to your doctor, who will be able to help and advise you about what your options are next.
My girlfriend has told me she’s pregnant - how can I be sure it’s mine?
Unfortunately, the only way to be sure that you are the father of her baby is to take a DNA test, which can be carried out several weeks after the baby is born. To do this, you will need the consent of the
mother, as samples of DNA will need to be obtained from the child (and possibly from the mother too). DNA (deoxyribonucleic acid) is found in our body cells and is responsible for our genetic makeup and hence our characteristics. DNA is identified in a blood sample or from a scraping of cells inside the cheek. Samples from the child and partner need to be obtained in the same way,
I drank and smoked quite a lot before I realized I was pregnant. Will this affect the baby?
As you are probably aware, it is not advisable to drink and smoke during pregnancy. There are, however many women in your position who did not realize they were pregnant and continued to smoke and drink The important thing is to stop drinking and smoking now and take the best possible care of yourself and your baby As many young women ”binge drinks’, it is important for women of child-
bearing age to be aware that alcohol does cross the placenta and is a toxic substance to the baby. Most women, once they realize they are pregnant, stop drinking immediately and this is the best course of action for you to take.
If a mother continues to drink heavily, the alcohol can adversely affect the developing fetus, especially between weeks 4 and 10 of pregnancy, and serious complications, such as fetal alcohol syndrome and fetal alcohol spectrum disorder can develop. If one of these conditions develops, it can result in physical, behavioural, and learning disabilities that can have lifelong implications for the baby Drinking in pregnancy also increases the risk of miscarriage and premature labour.
The harmful chemicals in smoke can restrict the baby’s growth and cause dependency on nicotine even within the womb (see p 42) so give up now
I haven’t got any pregnancy symptoms yet - when are they likely to start?
Not everybody feels the full range of pregnancy symptoms as soon as they become pregnant, and it is not uncommon for some women to experience none at all. There are many factors that influence the range and intensity of pregnancy symptoms, such as your age, working environment, your state of health, diet, previous pregnancies, smoking, and how your body reacts to pregnancy hormones.
Nausea and vomiting are among the most common symptoms that women report, usually in the first three months and starting at around six weeks. These tend to improve by 12 weeks, but for some women can continue throughout the pregnancy.
Another early pregnancy symptom is breast tenderness, which is caused by changes in the levels of hormones that help to get your breasts ready for breastfeeding. The breasts may enlarge and become tender and heavier.

My partner doesn’t seem as enthusiastic as me about the pregnancy - should I be worried?
Men and women can react to the news of a pregnancy in different ways and for many men, coming to terms with a pregnancy can take far longer. It’s worth bearing in mind that during the early stages of pregnancy, men can find it hard to relate to the pregnancy as they have yet to see their baby on a scan or the changes in your body On the other hand, you may be very aware that your body is undergoing many physical and emotional changes.
It’s likely that your partner simply needs more time to adjust to the news. He may be concerned about the changes to your lifestyle and the financial implications of having a baby Talking openly to each other can help to ease anxieties for you both.

First signs of pregnancy
The most obvious initial sign that you are pregnant is a missed period. Other common early pregnancy symptoms include feeling extremely tired and bloated, having increasingly tender breasts, experiencing an increased need to pass urine, and finding that you have a greater or lesser sex drive, although all of these symptoms can occur premenstrually Some women also experience a small bleed around the time their period was due: which may be confused with a lighter period, that occurs when a fertilized egg implants in the wall of the uterus. There may also be a metallic taste in the mouth, nausea or vomiting - described as morning sickness, although this can occur at any time of day Some women don’t experience any symptoms.

A surprise pregnancy
dealing with unexpected
If your pregnancy was unplanned, you may have to work through feelings of shock and anxiety before coming to terms with this life-changing event.
* Be open with your partner about your feelings and reassure him that this is as much of a shock for you
* Rather than feel anxious about your lifestyle, make positive changes straight away! adopt a healthy diet, stop smoking and drinking, and take folic acid (see p.15). *You may feel overwhelmed, but rather than despair, just allow yourself time to adjust physically, mentally. and emotionally
These early symptoms may settle around the middle of the pregnancy A lack of symptoms is not indicative of how healthy your pregnancy is - you may just be one of the lucky few who sail through with no annoying side effects’.