Before your booking appointment

ANTENATAL CARE - BEFORE YOUR BOOKING APPOINTMENT

Who's who in antenatal care

Your midwife

A midwife is a specialist nurse, trained in looking after you and your baby before, during and just after your delivery. If your pregnancy is normal, you may never meet a hospital doctor, but you will certainly meet at least one midwife during your pregnancy. Three quarter of the babies in this country are born with the help of midwives alone.

Most midwives tend to work in small teams. They may be based in hospital, in a midwifery unit or attached to a GP's surgery. You may have a named midwife who leads and co-ordinates your care. In some areas, it is possible to have the same midwife looking after you during your pregnancy and labour.

Once you have had your baby, you will be visited at home by a midwife until 10 (or occasionally 28) days after delivery. These midwives will usually not be the same as the midwives you meet before you have your baby. They will usually be attached to your local hospital - whether or not you have had your baby there.

Independent midwives

A small number of midwives work privately, outside the NHS. They charge for their services, but they do promise to provide continuity of care. Your private midwife will look after you throughout your pregnancy and labour - whether at home or at hospital. Most of them are trained and experienced in water births and home births.

You can find out more about independent midwives by contacting the Independent Midwives Association on 01483-821104.

Your GP

Everyone resident in this country is entitled to be registered with a GP. Your GP will be responsible for general medical care not related to your pregnancy. They will often share your antenatal care, too. Shared care is the most common form of antenatal care in this country. You will be seen by a midwife or hospital doctor for some appointments, and by your GP for others. Many GP's surgeries have midwives attached to them - they may provide a shared antenatal clinic, run jointly by the GP and midwife.

In some areas it is possible to book your antenatal care directly with a midwife. Otherwise, you will be referred for antenatal care by your GP.

Some areas have GP-led units, where your GP can deliver your baby. Some GPs provide intra-partum care - that is, they are qualified to look after you during your labour and delivery. Most GPs do not provide this service, though. If you want this service, you might consider transferring temporarily to the list of a GP who can provide intra-partum care. However, you are entitled to have a home delivery by a midwife even if you do not have GP cover.

Your obstetrician

An obstetrician is a consultant doctor with special training in the complications of pregnancy and labour. If you are referred to a hospital for hospital or shared antenatal care, you will usually have a named consultant. This consultant will be contacted if there are any problems before, during or just after your labour. You may not need to meet them or their team if your pregnancy goes smoothly.

You do have a right to see an obstetrician at your antenatal appointments or when you are in hospital - just ask if you would like to.

Your obstetrician will usually be in charge of a team of doctors including senior house officers (SHOs) and Specialist registrars (SpRs). These doctors are at different stages in their specialist training, but they will keep your consultant informed and ask advice as necessary. If you go into hospital outside normal working hours, you may be under the care of the duty team at first. However, your care will be transferred back to "your" obstetrician as soon as possible.

Your paediatrician

A paediatrician is a doctor with special training in the care of sick babies and children.

If your baby needs to be resuscitated - if they need help to start breathing after they are born - or checked out straight after delivery, this will be done by a paediatrician. A paediatrician will usually examine your baby routinely before you leave hospital. If you have your baby at home, or go home soon after delivery, your GP may do this first baby check.

Neonatal Intensive Care units and Special Care Baby units are headed by consultant paediatricians. They work with nurses trained in the care of new babies and with other paediatric doctors.

Your Health Visitor

A health visitor is a nurse with further training in the care of children under five years old. They work in the community, and are usually attached to one or more GP's surgery. Your health visitor will be told about your baby's birth automatically. They will visit you at home after the baby is ten days old. They usually carry out many of the routine child health surveillance checks your baby will need in their first few years of life. This will include regular checks of your baby's weight and development. They are also an invaluable source of advice on everyday concerns about your baby.

Some terms used in your antenatal notes

G_P_ This stands for "gravida (number of pregnancies) para (number of births), e.g. G1P0
ANC antenatal clinic
Trimester Pregnancy is divided into three trimesters, each of which is about three months
FHHR Foetal heart heard regular
FMF Foetal movements felt
Ceph Cephalic, or baby's head down into your pelvis
Breech Breech, or bottom-down, presentation
N/E Not engaged - the widest part of your baby's head has not moved down into your pelvis
Lie (for instance, LOA, ROL etc) The way your baby's back is facing. LOA means that the back of your baby's head - the occiput - is on the left side of your tummy at the front - anteriorly. It stands for left occipito anterior. ROL means the occiput is at the right side of your tummy to the side - laterally.
OP position If your baby's occiput and spine are at the back, against your spine, it can make labour more difficult.
Urine NAD No abnormality detected (on checking for protein and sugar)
CTG Cardio-tocograph - a tracing of your baby's heart rate and your contractions

Your first antenatal appointment

Your first hospital antenatal appointment is called your booking appointment. It is also usually your longest - so take a good book and set aside half a day for it. You will often have your first ultrasound scan at this appointment. Feel free to take your partner with you if you want them to see it, too.

At your booking appointment, you will be asked a number of questions. At some hospitals, you will be sent a questionnaire asking these questions in advance. You should take this questionnaire to your booking appointment.

Questions may include:

details of any previous pregnancies
your past medical history
your general health
your ethnic origin (some conditions, like sickle cell anaemia and thalassaemia, are more common in women of certain ethnic groups)
any medicines you have taken since you became pregnant
any allergies (especially to medicines)
any family history of medical problems
whether you smoke
whether you drink alcohol

Your booking appointment is a good chance to ask the questions you want as well. Areas you may have queries about might include:

your choices for antenatal care
whether a home birth is possible - or safe - for you and your baby
the effect of pregnancy on any medical problems you have
what sort of exercise you can do
what antenatal classes are offered by the hospital
what other antenatal classes are available in your area

You will probably also be examined at your booking appointment. Routine checks include:

your weight (this may only be done routinely at your booking visit)
your heart and lungs
your tummy (to check your baby's growth)
your blood pressure

Routine tests at your booking appointment will include:

Urine test - this will usually be checked for sugar and protein at every appointment. Sugar in your urine can be a sign of diabetes, and protein can indicate a urine infection or a condition called pre-eclampsia. Take a small sample with you in a clean, rinsed container.

Blood tests for:

haemoglobin - to check if you are anaemic. If you are, you may be offered iron and folic acid tablets, and you may need more frequent blood tests.
blood group - to check for a substance in your blood called rhesus factor. If you don't have this substance - and 1 in 4 or 5 women don't - you are known as rhesus negative. If you are rhesus negative and your baby is rhesus positive, your body can occasionally become "sensitised" to your baby. This means that it will see a future baby as an intruder and try to fight it off, the way it fights off infections. This can cause a problem with that baby's blood when they are born. Fortunately, this can be prevented by giving you an injection.
rubella antibodies - to check if you are immune to german measles. This is usually a mild illness, but it can damage your baby if you catch it in the early stages of pregnancy.
syphilis - this is a sexually transmitted infection which is rare. If it is discovered, however, you can be treated for it before your baby is harmed.
double or triple test - this is one of the investigations for foetal abnormalities. It will give an idea of your risk of having a baby affected by Down's syndrome or spina bifida. It can tell you if you are at low or high risk, but it does not give an absolute answer. For more details, see the section on testing for foetal abnormalities.
HIV antibodies - this test is completely voluntary. However, if you are affected, knowing this early can help staff to reduce your chances of passing the infection on to your baby.
other tests - will be carried out if you want them and they're appropriate, or if you are at risk of inherited conditions like thalassaemia or sickle cell anaemia.

Ultrasound - you will normally be offered an ultrasound examination at your booking appointment. This test uses sound waves to check your baby. It is completely safe and painless. It can check how many babies you have, their size and growth. Later in pregnancy - at about 20 weeks - you may be offered another ultrasound scan. At this stage it is possible to see your baby in much more detail. This scan can check for problems with your baby's spine, limbs, heart and other organs.

Later antenatal appointments

You will usually be given your antenatal records to keep with you after your first appointment. Do take them with you at all times - it is important for professionals who see you to know what has been going on with your pregnancy.

Depending on the type of care you are having, your later antenatal appointments may be at your GP's surgery, at the hospital, or with your midwife at home.

How often you will need to be seen will depend on your health, whether it is your first pregnancy, among other things. Your antenatal records should tell you when your appointments are.

Where to have your baby

Hundreds of years ago, women took it for granted that they would have their baby at home. In recent years, most babies have been delivered in hospital. Over the last few years, though, maternity care has gone through a lot of changes. It is now accepted that pregnancy is not an illness, and that involving women in making their own choices in pregnancy is very important. More and more options are becoming available for you to have your baby safely, but in a way you want. What options are available varies across the country. Do ask about the choices in your area.

Some of the places you can give birth include:
- Hospital. Not all hospitals have the same facilities, but all can deliver your baby by caesarean section if a problem arises, and have facilities for resuscitating your baby. Some have birthing centres attached to them, where you can have more "home comforts" and can make yourself more at home.

Midwife unit

These centres are run entirely by midwives. If you have one in your area, and you don't have medical problems, you should be able to have your baby delivered by one of the team of midwives who cared for you during your pregnancy. She, or a member of her team, can visit you at home after your delivery.

DOMINO scheme

Domino stands for "domicilliary - in - out". This means that your midwife visits you at home; that you go into a midwife-led unit to have your baby; and that you go home soon afterwards. You can often be in and out within a few hours if all goes well.

GP unit

In some areas, your GP can deliver your baby themselves in a unit with midwives and hospital doctors attached.

Home birth

You do have a right to have your baby at home. You have a right to have a midwife attend your birth even if your decision to have your baby at home is against medical advice. It is illegal in the UK for anyone other than a midwife or doctor to deliver a baby except in an emergency.

Many areas now have teams of midwives working within the NHS, who can deliver your baby at home. It is important to try and plan your home birth in advance - for a smooth delivery, you'll need more than hot water and towels! So ask about home deliveries at your booking appointment. You may want to consider booking an independent midwife to look after you - although these midwives will charge for their services.

- In a private hospital or private ward under a consultant obstetrician. If you opt for a private delivery, your consultant will charge you for his services and for staying in hospital privately. Your consultant will deliver your baby personally.

Your baby's development

Your baby's sex
The sex of your baby depends on their chromosomes. These are the "building blocks" that programme how your baby develops. There are two sex chromosomes - x and y. Your baby will have two of these, one each from you and their father. Your baby will always get an x chromosome from you. They have an equal chance of getting an x or a y chromosome from their father. If they inherit an x chromosome, they will be female - and if they get a y chromosome, they will be male.

Your baby's organs and growth

Heart - your baby's heart develops very early. By six weeks into your pregnancy, an ultrasound scan should be able to pick up your baby's heartbeat. This is much quicker than yours, but don't worry - it's supposed to be. Your baby's circulation works differently from yours, because your baby's oxygen supply comes from your blood stream rather than through their lungs. However, the structure of your baby's heart is the same as yours. Any abnormalities can usually be picked up at your detailed ultrasound scan at about 20 weeks.

Spinal cord - your baby's spinal cord is almost fully developed by twelve weeks into your pregnancy. One of the problems that can affect your baby's spine is a condition called spina bifida. In this condition, the two sides of your baby's spine do not connect properly. This can be mild - and may cause your baby no serious problems - but it can cause problems with walking or even be fatal. Taking enough folic acid in the first twelve weeks of your pregnancy can reduce your chance of having a baby affected by spina bifida by up to three quarters. You should take a folic acid tablet of 400 micrograms every day from when you start trying to get pregnant until you are twelve weeks pregnant, and increase the folic acid in your diet. If you have had an affected baby before, or if other members of your family are affected by spina bifida, you may be advised to take a higher dose - talk to your GP or midwife.

The size of your "bump"

You may feel pregnant at a very early stage, even before you miss a period. Symptoms include feeling sick; needing to pass water more often; swollen or tingling breasts; going off certain foods; increased vaginal discharge; or a strange metallic taste in your mouth. Your body will start getting ready for pregnancy right from the start. One of the changes you may notice is putting on weight on your tummy - even before your "bump" can actually be felt. Once you reach about twelve weeks of pregnancy, your womb will have grown enough to be felt above your pubic bone. By about 24 weeks of pregnancy, your womb will reach about up to your belly button, and by about 36 weeks of pregnancy, you will probably feel as if there is nothing in your tummy except baby!

Your baby's movements

One of the most exciting landmarks of pregnancy is the first time you feel your baby move. This tends to be about 18 to 20 weeks into your first pregnancy, and 16 to18 weeks into later pregnancies- although your baby will have been making movements you can't feel long before this. It can be hard to know at first whether you are feeling your baby move or not - especially in your first pregnancy. At first it might feel like wind or butterflies in your lower tummy. Later in pregnancy your baby's movements get much more vigorous, but don't worry if you don't feel anything for a few hours - babies sleep too, you know! Occasionally, not feeling movements for a long time can suggest your baby is in trouble. Do talk to your midwife about signs to look out for and what to do. Your baby tends to move most vigorously between about 30 and 32 weeks of pregnancy. After this their head is usually fixed into your pelvis and there is less room to move around.

The position of your baby

- in the early stages of pregnancy, your baby has plenty of room to float around in their fluid-filled sac in your womb. Until about 32 weeks into your pregnancy, many babies have their bottom facing down into your pelvis - a so-called breech presentation. By about 32 weeks - or slightly later in second and subsequent pregnancies - your baby will usually have turned so that his head is facing down into your pelvis. This is called a cephalic presentation. About 19 out of 20 babies are head down by 34 weeks. After about 32-34 weeks of pregnancy, your baby is unlikely to turn back again if he is head down.
Once your baby is head down, your midwife will start to document how many "fifths palpable" your baby's head is. This means how much of the baby's head can still be felt outside your pelvis. The less of your baby's head that can be felt, the further he has gone down through your pelvis. Once the baby's head is less than three fifths palpable, it is described as having "engaged" in your pelvis. This usually happens before 38 weeks into your first pregnancy, but it may be later in subsequent pregnancies. Your baby's head may not actually engage until you're in labour. Once the baby's head has engaged, your chances of having a normal vaginal delivery go up.