Consultations during Pregnancy
After a positive pregnancy test, a General Practitioner should be consulted to obtain a referral for antenatal care. The GP will often refer for Antenatal Screening blood tests and sometimes for a dating ultrasound scan. Screening for carriage of autosomal recessive disorders and X-linked disorders may also be offered.
The first antenatal visit occurs around 8-10 weeks gestation and takes about 45 minutes. At this visit an ultrasound scan is performed to confirm gestation and the fetal heart is checked to confirm viability. A complete medical history is recorded and any possible concerns discussed. Weight and blood pressure are recorded. Information is given about weight gain and maintaining health during pregnancy.
Information is given about screening during pregnancy. Referrals are given for the Nuchal Translucency screen which is due around 13 weeks gestation and for the blood tests that go with this scan to comprise the first trimester combined screen for chromosomal abnormalities.
Information is given about fees and booking into the hospital. After this visit it is time to book into the hospital and book Antenatal classes for later in pregnancy if required.
A booking needs to be made at an ultrasound service provider for the 13-week nuchal translucency scan. The blood tests that go with this scan need to be collected around a week (at least three working days) before the scan.
This blood collection is an opportunity to collect any Antenatal screening bloods that have not been collected already and to have a Non-Invasive Prenatal blood test if required. Screening blood tests for carriage of recessive genes may be collected especially if there is a concerning family history.
Subsequent antenatal visits take around 15 minutes and are initially 4 weeks apart. At each of these visits the fetal heart is checked and the weight and blood pressure recorded. Results of the Nuchal Translucency screen (and Non-Invasive Prenatal test if collected) are discussed. Further investigations are considered if these results are not reassuring.
A referral is given for the 20-week morphology ultrasound scan and the results are discussed at a subsequent visit.
A referral to a pathology provider is given for a Glucose Tolerance Test after 26 weeks which is a screen for diabetes. At the same time blood tests can be taken to check haemoglobin, iron levels and to detect any red cell antibodies.
After 28-30 weeks the visits are every fortnight and then visits are weekly after 36 weeks. Blood pressure may become high or concerns about fetal well-being may develop during these last few weeks. More frequent visits provide opportunities to discuss the impending birth.
Around 29 weeks it is recommended to have the whooping cough vaccine given by a General Practitioner. In response to this vaccination, antibodies will be produced that pass through the placenta and later through the breast milk. These antibodies provide baby with passive immunity and help protect baby from whooping cough infection before they receive their own whooping cough vaccination at six weeks of age.
If the maternal blood group is Rhesus negative, then preventative doses of Anti D are given around 28 weeks and 34 weeks gestation. This helps to prevent sensitization from tiny amounts of fetal blood leaking asymptomatically into the maternal circulation.
Around six weeks postpartum there is a visit to check recovery from the delivery. This visit is an opportunity to discuss the delivery and any issues arising from the delivery.
Any problems with feeding or the breasts are discussed. By this visit the postpartum bleeding should have resolved. A reminder is given regarding pelvic floor exercises and any problems with leakage of urine are discussed. If there are pelvic floor concerns, a visit to the physiotherapists for more intensive pelvic floor therapy may be needed. Any concerns about bowel motions, constipation and haemorrhoids are discussed.
A plan is made for contraception. Condoms can be used.
It is traditional to use the progesterone only (or Minipill) for contraception. A small amount of progesterone is taken every day so there are no sugar pills or withdrawal bleeds. The minipill is not as strong a contraceptive as the combined pill. It takes a full seven days to be covered. If a minipill is missed by more than 12 hours, there will be inadequate contraception for two days after the next minipill is taken. It is best to take the minipill at the same time each day within an hour or two. If good habits of taking the minipill are obtained it will work for during weaning and if periods return while breastfeeding. Recent research suggests that the Combined Oral Contraceptive pill does not affect milk supply and this may provide better contraception.
Resumption of periods varies a lot. Some women who are fully breastfeeding will have their periods return around six to eight weeks and will be fertile from then. Some women will not have periods until after ceasing breastfeeding even if they feed for a year or more. By six months postpartum 50% of breastfeeding women will have resumed periods. The first ovulation before the first period may not have usual ovulation symptoms. If there is no contraception, some women will fall pregnant at this ovulation without having any periods in between pregnancies.
Other progesterone-only contraception can be provided by Depo Provera injections which last for 3 months, the Implanon pellet which is inserted under the skin of the arm which lasts for 3 years, or the Mirena progesterone device which is inserted in the uterus and lasts for 5 years.
With the low oestrogen levels of breastfeeding, there may be symptoms of a tight, dry vagina. A script for topical oestrogen cream can be given for these symptoms.
At the postpartum visit blood pressure and weight are checked. Any repairs of the perineum or the Caesarean section scar are checked. An ultrasound scan checks that the uterus is back to normal. A Cervical Screening Test is collected if required.