The booking visit

The Booking Visit & the Obstetric History

Commonly women will have their pregnancy confirmed by a general practitioner or other doctor (for example, family planning or sexual health physician) who may arrange initial “booking” blood tests and an ultrasound scan to confirm pregnancy viability and dating. If women are low risk, they will then be recommended to book with an LMC of their choice. 

Broad aims of the booking visit: 

1. Taking a detailed  medical and obstetric history for risk of common late pregnancy complications e.g. preeclampsia, small for gestational age babies and spontaneous preterm birth
2. Providing treatments and additional screening for women with major risk factors
3. Discussion regarding prenatal screening for Downs syndrome and Other Conditions (see later)
4. Discussion regarding smoking and other modifiable exposures in pregnancy such as alcohol and substance use
5. Assessment of social risk and personal safety
6. Referral to support networks and other services as appropriate
7. Discussion regarding optimistion of pregnancy weight gain which if achieved will reduce the chance of late pregnancy complications  such as large for gestational age babies, gestational diabetes, preeclampsia, and Caesarean birth.

If you haven't watched the Taking an Obstetric History and General medical history at a booking visit video by Dr Olivia Payne, you should watch it now: click to play, right click to download 

The first visit (the booking visit) should take place in the first trimester. We have discussed the aims of this booking visit above. A thorough medical, surgical, psychiatric, and family history should be taken. A targeted examination is then performed and specific investigations are organised. A care plan for pregnancy will be formulated, and recommended investigations and visits for the pregnancy can be discussed.  

History

Personal details

• Age 
• Women under 18 years of age and over 35 years of age have additional obstetric risk factors
• Ethnicity 
• Ethnicity can also point us towards risk factors for certain medical conditions e.g. β-thalassemia in Mediterranean and Southeast Asian women
• Occupation 
• Whether the women is undertaking education, in employed work or working in the home impacts on her medical and social health as well as her health literacy

Current pregnancy

• Last menstrual period (LMP) and discuss cycle reliability and regularity 
• If the woman knows her LMP then the estimated date of delivery (EDD) can be calculated using a gestation calculator 
• If uncertain dates or other concerns (e.g. bleeding) then a dating ultrasound is recommended (this is the most accurate method of determining the gestational age of the pregnancy) 
• Planned or unplanned pregnancy 
• Symptoms of pregnancy (see later topic for more information)
• Nausea, vomiting, dysuria, constipation etc 
• Vaginal (PV) bleeding or abdominal pain 
• These are also important questions to continue asking at each antenatal visit 
• Use of folic acid and iodine 

Obstetric history

• Previous pregnancies (gravidity and parity) and the gestation completed and outcome of those pregnancies 
• Miscarriage
• Molar pregnancy 
• Termination of pregnancy 
• Ectopic pregnancy 
• Normal vaginal birth (NVB), instrumental birth, or Caesarean birth 
• Pregnancy complications in previous pregnancies in each trimester, especially: 
• Hypertensive disorders 
• Fetal growth restriction (this can be ascertained by calculating the growth percentile of previous babies based on their weight) 
• Preterm birth 
• Fetal or neonatal loss 
• Other pregnancy problems 
• Psychiatric complications in pregnancy (depression is the most common) 
• Details of previous births 
• Type of birth (NVB, instrumental birth, or Caesarean birth) 
• Obstetric trauma 
• Postpartum haemorrhage 
• Lactation 
• Any other postpartum complications (such as infections, postpartum mental health issues etc) 

Gynaecological history

• Date and result of last cervical smear 
• If she has ever had an abnormal smear, ask about colposcopy visits and possible treatments, such as a LLETZ (large loop excision of the transformation zone) or cone biopsy 
• Previous sexually transmitted infections (STIs) or pelvic inflammatory disease (PID)  
• These point towards a higher risk of STIs in pregnancy and the possibility of pelvic adhesions 
• STIs in pregnancy increase the risk of preterm labour and neonatal infection 
• Cervical or pelvic surgery 
• Important procedures include laparotomies (increased risk of adhesions), LLETZ/cone biopies, and any procedures that dilate the cervix (e.g. surgical evacuations for miscarriage and terminations) 
• Uterine fibroids 
• Fibroids can cause pain and pressure symptoms, abnormal fetal lie, and postpartum haemorrhage 
• If a woman has had surgery for fibroids in the past then this may impact recommendations on her mode of birth 
• Endometriosis 
• This can increase the risk of subfertility and infertility and may increase the risk of pelvic adhesions 
• Polycystic ovarian syndrome (PCOS) 
• Women with PCOS have a higher risk of metabolic complications, including gestational diabetes 
• Assisted reproduction, including IVF
• IVF is associated with an increased risk of preterm labour and fetal growth problems
• It may also point towards an underlying pelvic pathology e.g. PID, endometriosis, PCOS 

Past medical history

• Past medical conditions e.g. hypertension, epilepsy, diabetes, asthma, rheumatic heart disease 
• Many medical conditions can impact on pregnancy 
• Recurrent urinary tract infection (UTI)
• Untreated UTI is a risk factor for preterm labour and preterm pre-labour rupture of the membranes (PPROM) 
• Blood transfusions
• This increases the risk of maternal blood antibodies, which may affect the pregnancy 
• Previous surgeries 
• Abdominal surgery is particularly relevant
• Anaesthetic issues in previous surgeries should be ascertained 
• Mental health history 
• Mental health problems are more likely to deteriorate in pregnancy and suicide is a leading cause of maternal death in NZ
• It is recommended that women are screened with these two questions:
• Do you currently receive or have you ever received treatment for a serious mental illness?
• Do you have a family history of serious mental health problems, including perinatal mental illness?
• Current medications 
• Check if the woman is taking any prescribed, over-the-counter, or alternative medicines 
• Ensure medications that the woman is taking are safe in pregnancy- the NZ formulary gives pregnancy categories with each medication listed (you will learn more about medication safety in pregnancy in Case 3) 
• Allergies 

Family history

• Hypertensive disorders 
• Women with a family history of preeclampsia in female relatives (this includes preeclampsia in the partner's female relatives) are at an increased risk of preeclampsia themselves 
• Venous thromboembolism (VTE) 
• A family history of VTE is important to elicit as pregnancy is a pro-coagulable state, and all women have a higher risk of VTE in pregnancy- this may be even higher if the family history suggests an inherited disorder 
• Diabetes 
• Women with a family history of diabetes are more likely to develop gestational diabetes 
• Other inherited disorders 
• This includes congenital abnormalities in babies, and other inherited disorders that may affect the mother 
• Stillbirths and neonatal deaths
• Psychiatric history 
• Women with a first-degree relative with bipolar affective disorder or schizophrenia have an increased risk of developing postpartum depression or psychosis 

Social history

• Smoking, alcohol, illicit drugs
• These will be covered in more detail in Module 2 
• Social supports, income, housing 
• Family violence 
• Unfortunately, pregnancy is a high-risk time for women to experience intimate partner violence 
• This will be covered in more detail in Module 2 

An appropriate systems review should be undertaken for any concerns elicited from the history. 

At the end of history taking, ensure there is time for the woman to ask questions or provide further information on anything they feel is relevant to their pregnancy care. 

Examination

General appearance 

• Signs of anaemia 
• Breathlessness
• Generalised oedema 

Height and weight 

• Both of these need to be measured (not estimated) at the booking visit
• Calculate the BMI (women with low and high BMIs are at risk for pregnancy complications) 
• At subsequent antenatal visits, the weight will be recheck to assess appropriate weight gain in pregnancy 

Blood pressure (BP) and pulse 

• BP is taken at the booking visit and every subsequent antenatal visit 
• This is a screening test for renal disease and chronic hypertension (HTN) as this may be the first time a pregnant woman has had her BP measured for years 
• The correct technique is to use a correct-sized cuff and take a manual measurement witht he woman relaxed and positioned either sitting or semi-recumbent at 45 degrees 
• A pulse is taken as a baseline measurement at booking, it is not routinely taken later in pregnancy unless complications develop 

Abdominal examination 

• Assess for scars, tenderness, size of the fundus 
• If booking in later pregnancy, the fetal lie and presentation should also be checked 

Cardiovascular examination 

• Mainly targeted at eliciting cardiac murmurs that may not have previously been identified 

Other examinations 

• Auscultation of the fetal heart- the fetal heart can be heard with a handheld doppler from about 14-16 weeks should be auscultated if the woman is booking late 
• Systems examination: 
• A targeted examination of other organ systems may be indicated, particularly for women with symptoms or relevant past medical history. This may involve examination of the eyes, breasts, thyroid, vulva, or legs
• Vaginal/pelvic examination: 
• This is not a routine part of the booking visit, however if the woman has not previously had a cervical smear, or one is overdue, a smear should be offered
• Women complaining of symptoms suggestive of a STI should also have a pelvic examination and swabs taken 
• All pregnant women are recommended to have screening at booking for STIs. If a woman is asymptomatic she can self-collect a swab- a pelvic examination is not required 

 All findings must be documented on the antenatal record. 

Investigations

The first set of investigations in pregnancy are also targeted at screening for health conditions that may impact the pregnancy. You will talk about these in your tutorial groups during Case 1. Tests include blood tests, a midstream urinie culture, and an STI swab (combined chlamydia, gonorrhoea, and trichomonas swab). An ultrasound scan may also be requested at booking if this is necessary to confirm dates or if there have been any symptoms. The following tests should be requested at booking for all women: 

• Haemoglobin- checks for anaemia

• Mean corpuscular volume (MCV)- checks for thalassemia and iron deficiency 

• Platelet count- checks for thrombocytopenia
• Blood group and antibodies
• Important for women who are Rh negative, as these women are at risk of developing anti-D antibodies in pregnancy if they are not given prophylactic anti-D for sensitising events 
• Some red blood cell antibodies (such as anti-D) can cross the placenta and cause fetal anaemia- women with these antibodies need specialist care 
• Blood group and antibody status is also checked later in pregnancy, usually between 24-28 weeks to check that antibodies have not developed during the pregnancy 
• Rubella antibody status 
• Women who are immune to Rubella are low risk for acquiring Rubella in pregnancy 
• Women who are not immune to Rubella should be advised to avoid contact with unwell people 
• If Rubella is contracted by a pregnant woman it can be transmitted to the fetus and (depending on the gestation when it was acquired) can cause eye problems, hearing problems, and heart damage 
• Hepatitis B & C antibody status 
• It is rare for hepatitis B and C to be transmitted to the fetus during pregnancy (unless there is very active disease with high viral loads), the risk for transmission is mainly at the time of the birth of the baby 
• Babies born to women with hepatitis B should be washed after birth and given both the hepatitis B vaccine and hepatitis B immunoglobulin
• Babies born to women with hepatitis C should be washed after birth and treatment of hepatitis C with antivirals should be offered to the woman to decrease the risk in the next pregnancy 
• There is no increased risk of transmission with hepatitis B or C with breastfeeding, and all babies need to be followed up to ensure subsequent testing is negative 
• Syphilis 
• Syphilis has become more common in New Zealand and there has been a corresponding rise in cases of congenital syphilis 
• Untreated syphilis in pregnancy can cause stillbirth and early untreated syphilis has rates of congenital infection of 70-100% of babies and can cause a variety of serious health problems 
• HIV status 
• It is important to elicit a woman's HIV status at the start of pregnancy as the risk of vertical transmission is low (0.1%) if the woman uses highly active antiretroviral therapy (HAART) and has an undetectable viral load 
• Women may also require IV antiretrovirals during labour and birth, and women with very high viral loads may be recommended to have a Caesarean birth (this reduces the risk of vertical transmission at high viral loads) 
• Breastfeeding is not recommended in New Zealand as there is a risk of vertical transmission in breast milk and breast milk substitutes are readily available 
• HbA1c
• This is an important screening test to detect impaired glucose tolerance (which increases the risk for gestational diabetes) or undiagnosed pre-existing diabetes 
• For women with known diabetes, the booking HbA1c can evaluate what glycaemic control has been like during conception and the first trimester- uncontrolled diabetes is a risk factor for fetal congenital abnormalities 
• Mid-stream urine 
• It is important to treat both UTIs and asymptomatic bacteruria in pregnancy 
• STI swabs 
• Cervical smear (if due) 

Folic acid and iodine 

• Pregnancy vitamins are recommended for all New Zealand women 
• Folic acid should be prescribed to all women up until 14 week's gestation to reduce the risk of neural tube defects (NTDs)
• Women at high risk of neural tube defects (e.g. diabetes) should take 5mg folic acid OD until 14 weeks
• Low risk women should take 800mcg folic acid OD until 14 weeks 
• Iodine (150mcg OD) should be continued throughout pregnancy and whilst breastfeeding 
• Ideally both folic acid and iodine should be taken for 1-3 months pre-pregnancy 

Pregnancy weight gain 

• Healthy weight gain in pregnancy is important to consider for all women
• This will be discussed more in Module 2, but suboptimal and excessive gestational weight gain increase risks of complications such as preeclampsia and fetal growth problems 

Other pregnancy testing  

• An outline should be given of the options for screening for Downs syndrome and other conditions (we will discuss this shortly) 
• Women should also be advised of the importance of an anatomy scan as a screening test for pregnancy problems 
• Women should be aware of the timing of diabetes testing later in their pregnancy and why this is important 

Diet and exercise 

• The booking visit is an excellent opportunity to give advice on healthy eating and exercise in pregnancy (we will discuss this shortly) 

Take some time now to look at the booking cards from three DHBs which are in your course book. Can you see how these consolidate information from history, examination, and investigations? During this next week, look at booking cards when you are seeing women with your team- has the information on these cards pointed towards any problems or complications that may have arisen in these pregnancies?