For new mums-to-be, finding out that you’re pregnant is mind-blowing! But so often times, that is nothing compared to the bewildering and mind-boggling ‘procedures’ that you’re expected to religiously follow upon stepping into the clinic for the beginning of your antenatal journey. Not to mention the feeling of being akin to a pincushion, being pricked and prodded for the seemingly endless examinations and tests. Thus, this write-up is aimed at enlightening all expectant mothers on what they should expect during these follow-ups and the reason they’re there in the first place. This is also a breakdown of what the contents of your pink book (the antenatal book/card issued by government facilities) means.
On average, an expectant mum would attend at least 8 antenatal check-ups during her pregnancy. However, someone with higher risks or who is having complications such as pre-existing diseases would be expected to have more visits. However, no matter how many visits are made, the important thing is that these visits are of good quality and thus, it is important that mums are aware of what these visits entails.
In Malaysia, expectant mums are expected to register for antenatal check-ups before 12 weeks of pregnancy. However, there is no stopping you should you want to make your first visit as soon as your pregnancy is confirmed. In fact, the earlier the better, as proper care can be initiated earlier to ensure optimal growth of your unborn child.
During the first visit, mums will be registered into the system and basic details are required; such as age, address, contact number, ethic group, occupation, number of previous pregnancies and children. Government clinics will also require details of the spouse. These personal and social data are asked for the following reasons:
- Address and contact number: To make it easy for home visits;
- Age: To assess any possible risk factors;
- Occupation of the mum and spouse: To assess their socio-economic status; and
- Ethnic group: To identify possible cultural practices during pregnancy.
You will then be asked for details regarding your medical history, which includes obstetric, gynaecological, surgical and family history. For obstetric history, expect the following questions, especially for expectant mums who are not so new in this arena:
- Number of children, pregnancy and the year of these previous pregnancies – birth spacing is an important indicator of possible risk. Someone who has a pregnancy gap of less than 2 years is considered to be at a higher risk, and a pregnancy gap of more than 5 years would be treated as a first-time pregnant mum.
- The age of the previous pregnancy – whether it was carried on till full term, preterm or prolonged.
- Any illnesses or complications during previous pregnancy – to identify and anticipate any problems.
- Mode of delivery during previous pregnancies and place of delivery.
- Previous baby’s condition – alive and well, or stillbirth.
- Whether the previous baby was breastfed or given formula feeding.
In gynaecological history, expect to indulge the following information:
- Menstrual history – the Last Menstrual Period (LMP), which is the date of the first day of your last menses, is used to calculate the Expected Date of Delivery (EDD) and the age of your fetus. However, take note that this is only applicable to ladies who has normal, regular menstrual periods.
- Any previous surgical procedures done for gynaelogical purposes.
- Previous Pap smear results.
Medical and surgical history is also very important to your caregivers. If you have been diagnosed previously with any diseases such as diabetes mellitus, hypertension, heart disease, renal diseases and others as such, and you may be on treatment, these information is crucial to your antenatal caregiver as some treatments or medications may be unsuitable for your growing baby or yourself during pregnancy. This may also change the plan of care for yourself, so don’t worry about revealing such things. Family history of certain diseases may also be useful for us caregivers, as certain diseases have familial predisposition and would put us at higher alert on what to look out for.
Your nurse will then want to know how you are coping with your current pregnancy. Thus, don’t be afraid or ashamed to divulge whatever symptoms you are having because these trained health workers have had ample encounters before and may refer you to the doctor should the need arise. They may even have some very sound advice or two on how to cope with certain symptoms during pregnancy.
After the round of information gathering, the expectant mums will be ushered in for routine physical examination which includes:
During the first visit, the expectant mum’s height will be taken. This is essential to estimate the size of her pelvis. Petite mums, especially those of a height of less than 145cm may have a small pelvis, thus may affect the normal spontaneous vaginal delivery of the baby during labour. If this is the case, these mums will be referred to the doctor for further assessment of her pelvis to gauge the suitability for spontaneous vaginal delivery.
The weight of the mum is taken during the first visit as a point of reference for subsequent antenatal visits. The growth and development of your baby is assessed via the recorded weight of each visit. During the first half of your pregnancy, an increase of 0.5kg of weight each month is normal. During the second half, an increase of 0.5kg per week is expected. If there is excessive weight gain, it may warrant a careful investigation into the cause, which includes oedema (presence of an excessive amount of fluid in or around cells, tissues or serous cavities of the body), polyhydramnios (an excessive amount, more than 2000 ml of amniotic fluid) and multiple pregnancies, among others. A decrease, on the other hand, may also necessitate investigations into why it is happening, including intrauterine growth restrictions. A static weight may either mean that the baby is not growing well, or the mum is not taking adequate nutrition.
Measurement and recording of blood pressure is very important and is mandatory during each visit. Conditions such as gestational hypertension or the more complicated version namely pre-eclampsia (A condition in pregnancy characterized by an abrupt hypertension (a sharp rise in blood pressure more than 140/90 mmHg), albuminuria (leakage of large amounts of the protein albumin into the urine) and oedema (swelling) of the hands, feet, and face), are the reasons behind all this as they may cause significant harm to both mum and the unborn baby.
Other than the ones mentioned above, the nurse would do a head-to-toe physical examination of the expectant mum. Besides serving the purpose of being a baseline for subsequent visits, this physical checkup may reveal further tests or further care that the expectant mum may need. At government facilities, experienced nurses will carry all these out. They would refer mums to doctors to get their heart and lungs checked or if they find anything that requires further attention. The nurse will also refer expectant mums to a dentist for routine examination.
The abdominal examination is something that some mums are uncomfortable of but please be informed that it is an essential part of your pregnancy checkup. By keeping calm and relaxed, the experience would definitely be a more pleasant one. There are reasons why your nurse would seem like they need to massage and prod your tummy. All these maneuvers are actually to check on your unborn bub, and the kind of information can be elicited are listed as follows:
- Size and shape of the uterus;
- Observation of baby’s movement;
- Estimation of gestational period or how far along a pregnancy is;
- Determine the presentation of the fetus and his/her position; and
- Determination of fetal heart location and number of heart beats.
If it is still very early in your pregnancy, some maneuvers would not be carried out but as the pregnancy progresses, expect to have them done for every visit.
Routine Screening Tests
Once the physical examination is completed, it is routine for first antenatal visits to include screening tests, such as those listed below:
- Urine test to look for presence of glucose (sugar) and albumin (protein) – Sugar is tested to detect gestational diabetes (diabetes in pregnancy) while protein can mean a few things. If it is found in your urine, it may indicate that there is something wrong with your kidneys. Later on during your pregnancy, presence of protein in the urine may indicate presence of pre-eclampsia (high blood pressure in pregnancy). Both these tests will be repeated during each visit.
- Blood group and rhesus factors – Rhesus status of a mum must be known to detect possible incompatibility between mum’s and baby’s rhesus factor.
- Blood sugar level to detect gestational diabetes mellitus – This is especially important if the mum has a previous history of having big babies or if there is family history of diabetes.
- Blood test for haemoglobin level – This is to check the level of haemoglobin, the carrier of oxygen in the blood. Often times, some mums may suffer from anaemia and this is easily prevented by consuming the right diet and certain supplements.
- Human Immunodeficiency Virus (HIV) screening test will be conducted but only after careful pre-test counseling by the caregiver and the mum gives her consent in written form for the test to be carried out. This test is useful in the sense that there are medications available that can prevent transmission of the virus from mother to the unborn child.
- Venereal Disease Research Laboratory (VDRL) will be carried out to detect syphilis, a sexually transmitted disease during early pregnancy.
- Hepatitis B surface antigen will also be carried out during the first visit.
- If a mum comes from a high-risk area of malaria, a test to detect its presence, namely the Blood Film For Malaria Parasite (BFMP) will be conducted.
- Routine ultrasounds are usually carried out twice: once in the first trimester to confirm the age of the pregnancy as well as to identify any abnormalities and number of fetus; and another one done during the last trimester mainly to ensure optimal growth of your unborn bub, his or her position and the position of the placenta.
Some of these tests will be done repeatedly throughout your pregnancy, as means of early detection of any possible conditions that commonly affect pregnant women, namely the urine test for sugar and albumin and blood test for haemoglobin.
An expectant mum should expect to receive the anti-tetanus injection. If this is your first pregnancy, the injection will be given as soon as you feel the first few flickers of movements from your unborn baby, expected to be between the 16th to 20th weeks of pregnancy. However, this does not mean that you should run to your clinic just to get jabbed. You would only need to mention it to your nurse the next time you see her and she would initiate the immunisation. The second dose would be given 4 to 6 weeks after the first dose. If this is not your first pregnancy, then you would only need a booster dose of the injection. However, if your last pregnancy was more than 5 years ago, then you would still receive 2 doses of the injection.
After assessment of the expectant mum, routine vitamin supplements will be given to safeguard the optimal growth of the unborn baby and to prevent iron deficiency anemia, such as iron tablets (or ferrous fumarate), folic acid, vitamin C and vitamin B complex.
A few parting points…
Antenatal check up benefits both mum and the unborn child. Thus, it is crucial to hop on the bandwagon and get the attention that you need. In Malaysia, we are lucky to be offered the best in both the government and private health facilities. However, please take note that not all clinics offer the same services. For example, in government clinics, your point of contact will mostly be the nurses while in private facilities, it is the doctor who will carry out all these check-ups.
Not all government clinics have ultrasound machines and thus you may be referred to the nearest doctor for an ultrasound appointment. Private facilities may be more smooth-running and have less waiting time. Government clinics, on the other hand, may take up more of your time waiting for your turn to be checked, due to the fact that there are more people there. However, rests assured that because of the protocol that had been established, there will hopefully be no compromise on your care, despite the long wait.
Regardless of where you choose to get your antenatal check-up, the guidelines that are mentioned above are the basic necessities that an expectant mum should receive. However, depending on the condition of the mum, for example if you are at the riskier end of the spectrum, or have any concurrent medical conditions, you may be referred to be cared for by the specialist. Thus, you can expect more tests or procedures.
Hope this benefits you and have a smooth pregnancy ahead.
Dr. Ayu Akida is a Public Health specialist. Her area of interest is family health, especially women’s health and infectious diseases. Find out more about her at The Team (Columnist) page.
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]