From conception to birth, care and support of a pregnant woman is paramount. This paper will discuss the routine care that a pregnant woman would expect to receive and study the common disorders that are seen in many pregnant women, at some point or throughout their pregnancy.

The first antenatal visit is the most comprehensive. For some women, this is in the first few weeks of pregnancy and for others; it may be as late as 12-14 weeks. It is often the first contact that the pregnant woman has with her health providers and can be quite daunting and scary. As the visits continue, it is normal that they are shorter but no less thorough. Most women will have visits that roughly follow a basic plan, with variations that are customized to the patient, any conditions or complications that arise.

The most important thing that needs to occur between a midwife and her client is the establishment of rapport. Having a good rapport with the midwife, allows the woman to open up about what is concerning her, whether it’s physical or emotional, but also allows the midwife to discuss things that may be quite confronting or awkward. For example, not every woman will have planned her pregnancy, and so therefore, there can be fear and apprehension about whether she wants to keep the pregnancy or not.
Being able to relax means the woman may reveal more about herself than she realizes, such as her general appearance (Dressed appropriately? Does her hair look dull or dry?) or even for signs of skin changes such as chloasma, which is quite normal or dry chapped lips, indicating perhaps dehydration or vitamin deficiency.

The age of a woman can also have a bearing on what happens during prenatal visits. For example, issues that we stereotypically apply to one age group can in fact affect the other.
Genetic testing is often discussed at the initial appointment so discussing fears, concerns and outcomes around this, is much easier when you have an established rapport especially around Alpha-fetoprotein levels which are often measured around 16 to 18 weeks and can be an indicator for neural tube defect requiring further testing.
Other blood tests taken throughout pregnancy monitor things like haemoglobin and red cell index to watch for anaemia, white blood cells monitoring for infection and platelets to check clotting ability plus syphilis serology and blood for typing specifically to look at the mother’s rhesus factor if she is unaware of it. Determining the woman’s blood type is designed to prevent her from forming antibodies against the blood of any subsequent rhesus negative pregnancies. If the mother has rhesus negative blood then the first dose of anti D is given at around 28 weeks, with the final dose around 34 weeks.
HIV screening can be performed if necessary, and is routinely offered but is optional. A glucose tolerance test is often performed but given the length of time it takes, but also the preparation required, this is often performed separately and at a time that is convenient to the woman from around 24 weeks.

Taking a comprehensive and in depth history is again a vital part of the initial visit. It incorporates a wide range of areas each of which is crucial in their own way.
Taking a medical history for the woman is important as it can reveal conditions which can have an impact on pregnancy such as diabetes, thyroid issues or pre-existing back issues. However it’s still important to know everything, as it could provide a baseline if any symptoms did develop during pregnancy.

A vaccination history is important, especially but not limited to rubella and hepatitis B. Most vaccinations can’t be given during pregnancy in the first and second trimester but generally the blood work taken at the first consultation will include antibodies for rubella & hepatitis B. The whooping cough vaccination can be given during the third trimester if the woman has decreased or no immunity to pertussis.

A gynecological history is also important with questions around menstrual periods such as how long a normal cycle is or whether they are unusually painful or heavy so the midwife can form a baseline perhaps for postnatal education. Its important to be aware of any preexisting conditions such as endometriosis or a history of any surgical procedures in the pelvic/lower abdominal area as these can lead to adhesions, may put the woman at risk of an ectopic pregnancy or require monitoring for possible caesarian section.

The physical examination of the pelvis and reproductive organs is focused around their health and anatomy. Examination of the external genitalia can flag any external issues such as STDs like genital herpes, infection of the lubricating glands, swellings or lumps in the vulva or labial lips.
Internal examination examines structure like vaginal musculature; pelvic organ location if possible and also allows a health screen of the cervix via speculum exam allowing visualizing and Pap smear testing. Determining the position, contour, consistency and tenderness of pelvic organs, examining the anterior walls of vagina, ovarian palpation for swellings or tenderness and examination of the posterior walls of vagina can flag any potential issues early in pregnancy.
Physical anatomy of the pelvis allows assessment the pelvic size and measurements to determine the type of pelvis the woman has. Although it could be possible for a woman to still deliver vaginally, different shaped pelvises mean different risks and identifying them early means that the midwife has an idea of what to expect.
Checking if the woman does regular breast checks, contractive history and whether they are up to date with biannual pap smears can flag any areas where education may be required. It also allows you to run through the expected effects of the rises in oestrogen and progesterone levels such as enlargement, tenderness and hypersensitivity of the breasts, darkening and enlargement of the nipples and areolas and darkening of the veins due to the increased blood supply. Also towards the end of the pregnancy around the beginning of the third trimester, the breasts can begin leaking a yellowish, thick substance called colostrum but this can actually start at any point during pregnancy.

In the same area, an obstetric history is also important. Not every woman has been pregnant before, but it’s important to know a brief history of any pregnancies, terminations or miscarriages. Getting the sex, date and place of each birth or termination allows you to not only source the records but also could flag complications or whether she, for example, received the anti D injection at the time. Gathering this information, also allows you to accurately determine her status with previous pregnancies.

A family history for general medical issues if also important with an emphasis on renal or heart issues and potential genetic or congenital defects or illnesses which would allow pre-planning of additional tests or ultrasounds to check for anomalies as the pregnancy progresses. There is also a link between direct female relatives (mother, sisters) having similar complications and types of labour it could flag any issues that may need further investigation or monitoring.

The physical assessment involves taking a clean catch urine specimen to test for bacteria indicating a possible urinary infection and also underlying protein, glucose or ketones in the urine. This is helpful as a baseline against potential warning signs of preeclampsia (proteinuria) or diabetes (glucose and ketones). Urine will often be tested regularly to check for these, but also if a woman complains of symptoms that could indicate a complication.

A baseline weight is also particularly important as it is normal to increase throughout pregnancy by around 10 – 15kg depending on height with a sudden or dramatic gain possibly be indicative of preeclampsia when combined with an elevated BP and having an initial height allows for the calculation of the woman’s BMI.
Taking vital signs (temperature, blood pressure and pulse) allows for the same observation throughout the pregnancy especially with preeclampsia and infections.

Some women feel their hair is fuller when pregnant however this isn’t generally accurate; the hair cycle is actually just slowing down. Its normal to lose around 5-15% of our follicles which is then replaced by new growth and due to higher levels of oestrogen, less shedding of hair and thicker tresses occurs with some women noticing that their hair becomes shinier during pregnancy.
The presence of dandruff should be noted, not that it is indicative of anything serious, but it allows you to reassure the woman that antidandruff shampoos and conditioner are safe during pregnancy.

Assessing the eyelids becomes vital when monitoring for signs of preeclampsia. This is because the eyelids can become swollen with proteinuria and hypertension – symptoms of preeclampsia.
Physically examining the neck can allow you to identify issues such as thyroid hypertrophy, which causes increased blood pressure and enlarged lymph nodes, which shouldn’t be enlarged.
Listening to the heart and lungs not only allows you to check for normal rhythm and rate with both the heart and lungs, no heart murmurs or abnormal lung sounds and allows you to explain why laying on the left side is best which is due to compression of the inferior vena cava from the weight of the uterus which can cause faintness, decreased circulation to lower extremities and low blood pressure.
Examining the spine assesses for preexisting scoliosis which may require a referral to a specialist and allows you to get a baseline for predicted changes and finding out she has preexisting back pain can idea of whether its changed in location and quality but also allow her to tell you if she requires or uses OTC pain relievers.

Assessing the foetus also plays a large role in the prenatal care of the woman. Depending on when the woman presents for the initial consultation, the foetal heart tones may be heard with a Doppler at around 10 – 12 weeks, however they aren’t audible with a stethoscope until around 18 – 20 weeks. Fundal height will generally start to be measured from around 12 – 14 weeks when the uterus reaches the symphysis pubis. As the pregnancy progresses, fundal height will be measured from the symphysis pubis to the top of the uterus. The measurements should correlate with a graph of acceptable measurements.
An ultrasound will be conducted around the initial consultation but generally only if the date of the last menstrual period is unknown, otherwise the first scan for morphology can be around 18 - 20 weeks.
Foetal outline and position begins to become important from around 28 weeks onwards with the hope the baby goes into the ideal cephalic presentation. Throughout pregnancy the foetus will continually move around in the uterus, shifting to the most comfortable position possible as they grow. However, during the final weeks of your pregnancy as space becomes short they will settle on the position they plan to be born in. For most babies this is the 'anterior' position, considered the best for an easier birthing experience; other babies adopt a variation on this theme such as posterior or breech. It is important that the midwife identifies the foetal lie with each third trimester visit and obviously at the commencement of labour.

Common pregnancy complaints can be within a specific trimester or plague a woman from beginning to end. Some of the more common ones include breast tenderness. Almost always caused by increasing levels of oestrogen, the best way to relieve the symptoms can be to wear a comfortable, supportive bra preferably with wide straps and no underwire.
Constipation can occur at any point due to slowed peristalsis in the bowel but the added additional weight in the uterus being against the bowel can make it worse. With constipation or alone, haemorrhoids can occur. To relieve the discomfort from both, using the bowels regularly, increasing dietary fibre and drinking lots of water can help. Lying in the modified Sims position relieves the congestion of the bowel veins and pain can be helped with witchhazel or cold compresses. Ultimately though, prevention is best.
Nausea or “morning sickness” as it often called, affects around 50 % of all pregnant women. There is no universal cause but rather most likely, it’s to do with high hormone levels and diminished gastric motility. To relieve or minimize discomfort motion sickness wristbands, ginger and increasing glucose intake especially first thing in the morning can all help, but ultimately in most women, it ends with the end of the first trimester.
Another common complaint especially in the first trimester is fatigue. This is thought to be mostly to do with the increased metabolic requirements of the body. The best management of this is increased rest & sleep, listening to the body and balanced nutrition.
The weight-distended uterus putting pressure on veins returning blood from legs causes varicose veins. It leaves the woman with engorged, painful and inflamed “ropes” anywhere from the vulva to the feet. There isn’t really a cure for them until delivery but prevention is the key. Resting in Sims position for 15-20 minutes per day, avoiding crossing of the legs, medical support stockings (TEDs) and exercise all can help prevent or minimize them.
Leg cramps especially in the first trimester are thought to be caused by decreased calcium, increased phosphorous and interference with circulation. The best treatment if and when they occur is exercises such as straighten the legs and pulling the feet only back towards the head (dorsiflexion) and avoiding toe pointing and high heels.

During the second trimester, backache can occur. Most commonly caused by lumbar lordosis or postural changes due to the changing centre of gravity, shoes with low – moderate heel, tilting of the pelvis and localized heat can all help soothe the pain or prevent it.
Headaches are another common complaint however monitoring of blood pressure is also vitally important due to the signs of preeclampsia. Expanding blood volume, eyestrain and tension are other causes, which are relieved by reducing stress and tension, cool towels on forehead and paracetamol as required.
Ankle oedema is another common complaint. It can be completely normal and tends to worsen by the end of day. It is a natural effect as long as not associated with proteinuria or high blood pressure. It can be caused by reduced blood circulation in lower extremities due to uterine pressure. It can actually be relieved or minimized by lying on the left side as it increased kidney filtration and elevating of the legs.
Finally Braxton-Hicks contractions…they actually occur throughout pregnancy but as a woman enters the third trimester they tend to become stronger and more noticeable. They are completely normal and not sign of labour; however it is important to educate the woman on the changes in contractions – more regular, shortening time between them.

Essentially women’s bodies go through an extraordinary amount of physiological and emotional change during pregnancy. Education and support is key to the midwife’s role, with assessment and examination forming the basis on which the care of the woman is based.