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Obstetrics & Gynaecology
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Routine Antenatal Care and Antenatal Appointments

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Introduction

In the NHS, all pregnant patients will be offered a number of appointments throughout their pregnancy as a part of their routine antenatal care. 

Lower-risk (“uncomplicated”) pregnancies will be midwife-led, with patients being offered ten appointments over the course of their pregnancy after the booking appointment if they are nulliparous. If it is a second (or later) pregnancy, this number is reduced to seven.

Higher-risk pregnancies will require obstetrician-led care; this includes factors such as multiple pregnancy or maternal health problems. These patients will be offered the usual midwifery appointments and joint clinics to manage additional risk factors.

This article will focus on the appointments offered as routine antenatal care for an uncomplicated pregnancy.

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Dating the pregnancy

The initial estimated due date is based on the first day of the patient’s last menstrual period. Adding nine months and seven days to this date will give an estimated delivery date, although this method assumes that the patient has a 28-day cycle and ovulates on day 14 of their cycle.

There are several due date calculators available online, some of which will consider different cycle lengths.

Following this, the progress through pregnancy is written as the completed weeks plus how many days into the week they are (e.g. 14 weeks and 1 day is 14+1 weeks).

Dating scan

This dating may be revised at the dating scan between 11 weeks and 13+6 as this is the most accurate point for USS dating of the pregnancy.¹

Booking appointment

The booking appointment is the first stage of antenatal care and is arguably the most important, as it is where an in-depth history, discussion and planning of future appointments take place.

Information is provided through public health campaigns to encourage women to book in with a midwife for their first appointment, either by direct booking or through their GP. Midwife clinics are often in the community, including GP surgeries and children’s centres.

This appointment lasts around an hour.

NICE guidance suggests the booking appointment should occur before 10 weeks of pregnancy, or if booked after 9 weeks, the appointment must be within 2 weeks of the booking date.2

History

During the booking appointment, all of the standard parts of a medical history should be covered, as well as some additional areas. 

For more information, see the Geeky Medics guide to obstetric history taking.

Maternal health

Maternal health is explored both to provide a baseline for health throughout the pregnancy and to alert maternity services of any extra need for monitoring or testing.

Conditions that should be specifically asked about include:

  • Diabetes (including previous gestational diabetes)
  • Heart conditions
  • Epilepsy
  • Specific maternal mental health problems

These are conditions that are managed by specialist multi-disciplinary teams. Mental health should be reviewed at subsequent appointments, even if there is no history of mental health problems.

Obstetric history

A comprehensive obstetric history is essential, including:

  • Gravidity: how many times a person has been pregnant
  • Parity: number of births of foetus aged over 24 weeks, whether living or not
  • Number of vaginal births
  • Caesarean births
  • Any complications maternal or foetal

Social history

Social circumstances include:

  • Housing
  • Smoking and alcohol misuse
  • Work status of pregnant person
  • Social support network

It is also important to sensitively ask about domestic abuse at the booking appointment, and subsequent appointments.

Examinations

If the booking appointment is face-to-face, the patient’s height and weight should be measured, and a BMI calculated. The patient should also have their blood pressure checked.

Investigations

Bedside investigations

A urine dipstick test should be completed at the booking appointment to confirm pregnancy (beta HCG) and check for proteinuria.

Laboratory investigations

Several blood tests should be taken at the booking appointment:

Screening

Screening should be offered for:

It is important to remember that the patient can accept or decline any of these screening programmes.

Information giving and follow-up

The booking appointment should include a discussion outlining the timeline of routine antenatal care, and given contact details for the midwifery team.1 Patients should also be counselled on:

  • Changes to expect during pregnancy
  • Recommended immunisations
  • Infections that can impact the baby (e.g. group B streptococcus)
  • Medication and supplements during pregnancy
  • Lifestyle 

They can also be signposted to further sources of information and peer support.

If any medical concerns have arisen, significant medical conditions have been identified, or medications need review, the patient can be referred to an obstetrician or other specialty as needed.

Other medical issues to discuss include:

  • Venous thromboembolism (VTE) risk: calculated per local guidelines due to increased coagulopathy in pregnancy, and anticoagulation may be offered
  • Folic acid supplementation (if the patient is not already taking): clarify the dose, as some patients should take the higher dose of 5mg depending on the risk of neural tube defects

Maternity notes

At the booking appointment, the patient should also be given their maternity notes:

  • Digital or physical book, often a folder
  • Record of all antenatal contact both planned and emergent
  • Brought to every appointment and should be encouraged to carry everywhere.

11+2 to 14+1 week scan

Dating scan

The “dating scan” appointment is offered between 11+2 and 14+1 weeks gestation. This scan has 3 functions: formal dating of the pregnancy, confirmation of number of foetuses and nuchal translucency measurement.

Dating occurs using crown-rump foetal length, measured using software, to give a gestational age and a due date 40 weeks from the estimated conception date. This may differ from previous calculations and maternal perception. This becomes the confirmed estimated due date (EDD).1

If the patient has consented to screening for aneuploidies then the nuchal translucency will also be measured at this scan. Some major abnormalities such as neural tube defects may also be seen during the scan.3 They will also have blood tests taken as part of the combined test and a risk score calculated as a ratio.

History and examination

If the booking appointment did not take place face-to-face, then the examinations and investigations listed above can take place at this appointment.

16 week (14-18 weeks) appointment

New points

Depending on the risk factors identified in the booking appointment and the local hospital guidelines, this appointment may be with a midwife or consultant obstetrician.

At this appointment, the results of previous screening tests are conveyed, with counselling as appropriate, depending on the results.

Whooping cough vaccinations are offered due to the risk to pregnancy, as well as commencing iron supplementation due to pregnancy-related anaemia.

For those at moderate-high risk of pre-eclampsia based on risk factors, 150mg aspirin once daily is started.4 The risk of fetal growth restriction can also be assessed at this appointment.

While it is still quite early in the pregnancy, a discussion around birth preferences and the risks and benefits of each choice should begin from this appointment, if not already discussed.

A Doppler can assess foetal heart tones from this appointment onwards, with measurement position changing throughout pregnancy as the uterus expands and the foetus occupies more space.

Reviews

History, examinations and investigations should include a review of:

  • General health: common issues in pregnancy include heartburn, hypertension, nausea and vomiting, pelvic pain, smoking, alcohol and unexplained vaginal bleeding
  • Domestic abuse
  • Mental health
  • Blood pressure
  • Urine dipstick: for proteinuria
  • VTE risk if there have been any hospital admissions/significant health events

20 week (18-20+6 weeks) scan

New points

The 20-week anomaly scan is an ultrasound scan of the entire foetal body, checking for 11 physical conditions, from a detailed brain scan for structural anomalies to confirming the development and growth of limbs. It is a long appointment and can be particularly nerve-wracking for patients who have had previously detected anomalies, pregnancy losses or family history of issues such as cleft palate.

This scan also checks for placental location. If the placenta is low, then the patient should be advised to avoid sexual intercourse, vigorous exercise and flying. They should be advised that most low placentas will move away from the lower segment by 32 weeks, so a placental location scan will be performed then to reassess the risk.

The position of the foetus can be particularly important to viewing all anatomical areas, so some patients may need to return for an additional scan for completeness if the foetus does not move.

This scan is standardised nationally and carried out according to the NHS foetal anomaly screening program for the following conditions:5

  • Anencephaly
  • Spina bifida
  • Edwards’ syndrome (T18)
  • Patau’s syndrome (T13)
  • Congenital diaphragmatic hernia
  • Gastroschisis
  • Exomphalos
  • Congenital heart disease
  • Bilateral renal agenesis
  • Lethal skeletal dysplasia
  • Cleft lip

Communicable disease screening also occurs, with specifics depending on maternal consent and local policies.

24 weeks

New points

If a patient is identified as high risk for gestational diabetes, they will have their OGTT between 24 and 28 weeks.6

25 week appointment

New points

This is the first appointment specific to people in their first pregnancy.

Movements are discussed, as most people will begin to feel definitive foetal movements between 18-22 weeks, and changes in movements should be investigated for issues with foetal health. Safety netting advice is given to the patient about which service to present to if they feel any reductions in movement, usually 24-hour maternity triage.

There has been a move away from counting the kicks, with the emphasis now on deviation from the previous kick pattern. Reduction in frequency or strength of kicks is cause for concern and assessment.

Symphyseal-fundal height (SFH) measurements begin, a measurement from the pubic symphysis to the top of the uterus. This measurement is plotted on a growth chart, and significant variance suggestive of a slow down in growth or a drop across 20 centiles will require an urgent fetal growth scan as this could indicate intrauterine growth restriction (IUGR), oligo or polyhydramnios or other issues.7

The SFH measurement is only suitable in certain cohorts. If the patient falls into a high risk for small for gestational age category or has a BMI >35 or fibroids, then they will require serial growth scans rather than SFH. This is due to these factors confounding the measurement of SFH.

Ongoing discussions about birth preferences should continue, as well as signposting to resources for expectant parents.

Reviews

History, examinations and investigations should include a review of:

  • General health
  • Domestic abuse
  • Mental health
  • Blood pressure
  • Urine dipstick: for proteinuria
  • VTE risk if there have been any hospital admissions/significant health events

28 week appointment

New points

SFH is measured (a repeat of the previous appointment for a primiparous patient) or for the first time this pregnancy in a multiparous patient.

Active labour and labour plans are discussed between the care team and patient, including locations available for delivery. Information should be given on:

The patient should also be advised to avoid sleeping on their back after 28 weeks gestation.

A repeat FBC and group and save are performed. Iron supplementation may be required if the patient is found to be anaemic. For patients with rhesus-negative blood types, anti-D prophylaxis is given to limit sensitisation to a possibly rhesus positive foetus.8

Movements are discussed, and safety netting advice is given to multiparous patients.

Reviews

History, examinations and investigations should include a review of:

  • General health
  • Domestic abuse
  • Mental health
  • Blood pressure
  • Urine dipstick: for proteinuria
  • VTE risk if there have been any hospital admissions/significant health events

31 week appointment

For primiparous women only previous history, examinations and investigations are continued to monitor pregnancy progression:

  • General health
  • Domestic abuse
  • Mental health
  • Foetal movements
  • Blood pressure
  • Urine dipstick: for proteinuria
  • SFH
  • VTE risk if there have been any hospital admissions/significant health events

34 week appointment

New points

For rhesus-negative patients, the second anti-D injection of the course is given.8

Birth preferences should be confirmed. For all patients, the possibility of a caesarean birth should be broached, with information given about why a caesarean may be needed, the process of an elective vs emergency operation, and what may be involved in recovery.7

Reviews

History, examinations and investigations should include a review of:

  • General health
  • Domestic abuse
  • Mental health
  • Foetal movements
  • Blood pressure
  • Urine dipstick: for proteinuria
  • SFH
  • VTE risk if there have been any hospital admissions/significant health events

36 week appointment

New points

 The postnatal period is the focus of this appointment, with information given about:

  • Newborn care
  • Newborn screenings
  • Vitamin K in the newborn
  • Mental health in the postnatal period
  • Postnatal health: including pelvic floor exercises

Abdominal palpation should be offered to patients with a singleton pregnancy to assess for possible breech presentation. If breech presentation is suspected, then it can be confirmed with an ultrasound.

For a fetus known to be breech/malpositioned external cephalic version (ECV) can be trialled at this point, with adequate consent and acknowledgement of risk if the patient doesn’t wish to opt for elective caesarean or vaginal breech birth.

Reviews

Review the current plan for the birth. History, examinations and investigations should include a review of:

  • General health
  • Domestic abuse
  • Mental health
  • Foetal movements
  • Blood pressure
  • Urine dipstick: for proteinuria
  • SFH
  • VTE risk if there have been any hospital admissions/significant health events

38 week appointment

New points

Options for ‘prolonged pregnancy’ or going past due date, including induction, caesarean for postdates, and the risk of being substantially postdates should be discussed.9

Reviews

Review the current plan for the birth. History, examinations and investigations should include a review of:

40 week appointment

This is another appointment that is only offered to primiparous women. Many units now offer a 40-week scan for fetal wellbeing. 9

Reviews

Review the current plan for the birth and discuss plans for prolonged pregnancy. History, examinations and investigations should include a review of:

41 weeks

New points

Due to going post dates and the increased risk for every day that a patient goes post dates of stillbirth, patients are offered a membrane sweep, which may put them into labour, or alternatively, a formal induction of labour.

A low-risk patient with no clinical reason to require it will be offered induction of labour at either 40+10 or 40+12, depending on local protocols.

If this induction of labour is declined, then they will likely have an urgent appointment with an obstetrician to discuss their decision and the reasons for induction at this gestation.9

Reviewer

Dr Matteo De Martino

Obstetrics and gynaecology consultant

Editor

Dr Jess Speller

References

  1. Tommy’s. Pregnancy due date calculator. Available from: [LINK]
  2. NHS. Your antenatal appointments(No date) NHS choices. Available from: [LINK]
  3. Public Health England. Screening in pregnancy: Dating scan. Available from: [LINK]
  4. Tan, M.Y. et al. (2018) ‘Comparison of diagnostic accuracy of early screening for Pre‐eclampsia by NICE guidelines and a method combining maternal factors and biomarkers: Results of Spree’, Ultrasound in Obstetrics & Gynecology, 51(6), pp. 743–750.
  5. Public Health England. NHS Fetal Anomaly Screening Programme (FASP): Programme overview, UK. Available from: [LINK]
  6. NHS. Gestational Diabetes. Available from: [LINK]
  7. Papageorghiou, A.T. et al. (2016) ‘International standards for symphysis-fundal height based on serial measurements from the Fetal Growth Longitudinal Study of the intergrowth-21stproject: Prospective cohort study in eight countries’, BMJ, p. i5662. 
  8. Qureshi, H. et al. (2014) ‘BCSH guideline for the use of anti‐D immunoglobulin for the Prevention of Haemolytic Disease of the fetus and newborn’, Transfusion Medicine, 24(1), pp. 8–20. doi:10.1111/tme.12091.
  9. Dr Hayley Willacy, F. (2022) Post-term pregnancy (prolonged pregnancy), info. Available from: [LINK]

 

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