Navigating maternity care: understanding each step of the journey

To mark Maternal Mental Health Month, our specialist maternity care team is reflecting on common themes of birth trauma shared by our clients. One issue raised time and again is that families felt they did not have the information they needed at each stage to make informed decisions.

Our team has sought to empower families by creating a series of articles that follow the maternity journey. These will look at what to expect, break down the plethora of terminology used along the way, and highlight some of the common themes that underpin the cases we see.

Antenatal care is designed to provide steady, structured support to help you stay well, while enabling your maternity team to identify any potential issues as early as possible. Within the NHS, this care is often midwife‑led for uncomplicated pregnancies, with doctors and specialist teams becoming involved when additional monitoring or treatment is needed for mum or baby.

Here we provide an overview of antenatal care, a detailed guide to key topics commonly led by midwives, and an explanation of how problems can sometimes arise, along with what you can do to seek support and help.

What is antenatal care?

Antenatal care is the care you receive during pregnancy to support your own and your baby’s health. It includes planned appointments, screening tests, scans, physical checks (like blood pressure and urine testing), and conversations about your wellbeing and concerns.

In the NHS, you will usually be offered:

• a booking appointment in early pregnancy (before your 10^th week of pregnancy);
• two routine ultrasound scans (dating and anomaly):
  • a dating scan should usually be scheduled between your 11^th and 14^th weeks of pregnancy. This scan calculates your estimated due date (EDD), checks the baby’s development, and can also be used as part of a combined screening test for genetic conditions like Down’s syndrome;
  • an anomaly scan should usually be performed between your 18^th and 21^st weeks of pregnancy. It is a detailed scan which checks baby’s physical development and internal anatomy, screening for 11 specific physical conditions;
• a schedule of routine antenatal appointments, with more if you have additional needs or risk factors. Routine antenatal appointments for an uncomplicated pregnancy are typically scheduled as 10 visits for a first pregnancy and seven visits for subsequent pregnancies. Care starts with the booking appointment and from week 36 runs weekly up to 41 weeks.

Antenatal care is an ongoing process of listening, documenting, assessing risk, and acting promptly if anything changes during your pregnancy. At every appointment, your medical team should check how you are, ask about concerns, review the plan, and update your records.

Booking appointments: what they involve and why they are important

You should be offered your first (booking) appointment by 10 weeks gestation, and if you contact maternity services later than nine weeks, you should be offered a booking appointment within two weeks of this date where possible. Your first midwifery appointment should take place at around 8–12 weeks gestation and may take about an hour.

Booking is where your midwife builds a full picture of your health and your circumstances so your care can be personalised to your needs. At the booking appointment your midwife should ask about your:

• medical history (including previous surgical history), obstetric history, and family history (of both biological parents);
• current and recent medicines (including supplements such as folic acid), allergies, mental health concerns, and lifestyle factors (smoking, alcohol, drugs, diet, activity);
• occupation and home situation (including support networks), and
• any safeguarding concerns in a sensitive manner (for example, domestic abuse).

You will also usually have baseline checks, such as blood pressure, urine and blood tests, and you will be offered information about screening programmes and scans.

A well-conducted booking appointment is very important as it helps your medical team to identify any conditions which will require extra monitoring (for example, diabetes risk, blood pressure risk, anaemia management, previous pregnancy complications), ensure you are offered the right tests at the right time, and make certain you know how to access help between appointments.

If you feel something important was not covered at your appointment, especially if this includes issues you experienced in previous pregnancies, long‑term health conditions, medicines, or relevant close family history, you should raise it at your next midwifery appointment. Your maternity team should make an ongoing risk assessment and record updates every time you meet.

Growth charts and measuring your bump

From mid‑pregnancy onwards, many midwives monitor baby’s growth by measuring the distance from your pubic bone (symphysis) to the top of the uterus (fundus). This is called the symphysis–fundal height (SFH) measurement. The measurement should be taken at each antenatal appointment after 24+0 weeks gestation, no more often than every two weeks, unless you are already having regular growth scans. The measurement should be plotted on a growth chart which is kept in your medical records and should make up part of checking your baby’s growth and discussing baby’s movements.

Growth charts help your team spot patterns that suggest your baby may be smaller or larger than anticipated, as well as growth that slows down or accelerates unexpectedly. SFH measures the uterus and its contents (baby, fluid, placenta) and is a screening tool rather than a precise way to weigh your baby. That is why the focus of SFH measurements is on documenting the pattern over time rather than looking at one isolated measurement.

The National Institute for Health and Care Excellence (NICE) advises that a scan should be considered:

• if SFH seems large for gestational age: a growth and wellbeing scan may be considered;
• if SFH seems small for gestational age: a growth and wellbeing scan should be offered, with urgency informed by other findings (for example, reduced movements or raised maternal blood pressure).

Many maternity pathways also use structured criteria for when to refer for ultrasound, such as when SFH measurements plot below certain centiles or show baby is not gaining weight or growing at the expected rate between ultrasound scans (slow growth velocity).

‘Large for dates’ (LGA): what it means, causes and possible complications

The term ‘large for dates’ is sometimes referred to as macrosomia and is used to describe a baby predicted to be over around 4kg at birth. It is important to remember that assessing whether a baby is ‘large for you’ very much depends on your individual characteristics.

Common reasons a baby may measure as large for dates include parental build/genetics, a previous large baby, diabetes (including gestational diabetes), and a higher maternal BMI.

If the growth pattern suggests possible large for dates, your care pathway may include an ultrasound scan to more accurately estimate baby’s size, assess amniotic fluid volume, and possibly a test for gestational diabetes where appropriate. It is also important to know that ultrasound weight estimates can be around 20% higher or lower than baby’s true weight, and sometimes babies are born average‑sized despite antenatal concerns.

If you are carrying a suspected large for dates baby, you may still have a straightforward birth, although it can also be associated with a higher chance of a prolonged labour and assisted birth (forceps/ventouse or caesarean), heavier bleeding after birth (postpartum haemorrhage), and perineal trauma (including more significant tears).

For babies, a key concern is shoulder dystocia (shoulders stuck after the head is born), which can be an emergency and may sometimes be associated with nerve injury, fractures, or reduced oxygen to baby’s brain.

If large for dates is suspected, your medical team should discuss your options with you and support you to make informed choices about monitoring and birth planning.

‘Small for dates’ (SGA/FGR)

If the estimated weight of your baby by ultrasound scan is in the lowest 10% of babies (the smallest 10 out of every 100 babies, or less than the 10th centile), they are considered to be small. There are different reasons why this may be the case: most babies do not have any health problems but are just smaller than others and this is normal for them.

Sometimes, however, babies are small because they have not grown as well as expected. This is called being ‘growth restricted’. The smaller your baby is, the more likely they are to be growth restricted.

Causes of growth restriction include:

• your placenta not working as well as it should – this could be because of medical problems or complications of pregnancy;
• catching certain infections (such as toxoplasmosis or cytomegalovirus, often known as CMV) while you are pregnant; or
• having a baby with an underlying developmental or genetic condition.

Many factors can increase your chance of having a small baby, including older maternal age (40+), low BMI, smoking or drug use, higher caffeine intake, some medical conditions (including high blood pressure, diabetes, kidney disease, autoimmune disease, and blood clotting problems), and prior pregnancy history of a small baby, pre‑eclampsia or stillbirth.

What happens next will depend on how small your baby is and how early in the pregnancy they have been found to be small. You may be offered the following tests to check their wellbeing:

• an umbilical artery Doppler scan – this is an ultrasound scan which measures the flow of blood through the umbilical cord. It can help to tell whether your baby is at risk of becoming unwell and if they may need to be born early;
• more frequent growth scans;
• additional Doppler scans checking the blood flow in your baby’s brain and abdomen;
• a computerised cardiotocograph (CTG) – this is a tracing of your baby’s heart rate.

You may be referred to a specialist doctor (a fetal medicine specialist) for more frequent and detailed scans if your baby is very small, particularly early in the pregnancy, or the umbilical artery Doppler scan is not normal.

Depending on your individual circumstances, you may be offered additional investigations to determine whether your baby has any genetic or chromosomal conditions (such as amniocentesis), or blood tests to screen for infections. Your blood pressure and urine will be monitored regularly to assess if you are developing pre-eclampsia. You will be advised to go straight to hospital for assessment if you are ever concerned that your baby is not moving normally.

Reduced fetal movements: trusting your instincts and seeking help promptly

Most women are first aware of their baby moving when they are approximately 18–20 weeks pregnant. However, if this is your first baby, you may not become aware of movements until later in your pregnancy. Pregnant women feel their baby’s movements as a kick, flutter, swish or roll.

Feeling your baby move during your pregnancy gives you reassurance of their wellbeing. If you notice that they are moving less than usual or if there has been a change in the pattern of movements, it is essential that you contact your midwife or local maternity unit immediately so that your baby’s wellbeing can be assessed.

The care you will be given when you report a reduction or change in your baby’s movements depends on the stage of your pregnancy and the guidelines within the hospital about what investigations should happen, but they may include checking your baby’s heartbeat using a handheld doppler or CGT, an antenatal check including measuring the size of your uterus, monitoring your blood pressure and testing your urine for protein, or an ultrasound scan to assess your baby’s growth and amniotic fluid levels. These investigations usually provide reassurance that all is well.

If there are any concerns for your baby, your healthcare team will discuss this with you. Follow-up scans may be arranged. In some circumstances, you may be advised that it would be safer for your baby to be born as soon as possible. This would depend on your individual situation and how far along you are in your pregnancy.

Testing for gestational diabetes (GDM): timing, risk factors and why family history matters

Diabetes that develops during pregnancy is known as gestational diabetes and affects at least 4-5 in 100 women. It happens because your body cannot produce enough insulin to control your blood sugar levels and meet the increased needs of pregnancy, leading to high blood sugar (glucose) levels. Gestational diabetes usually starts in the middle or towards the end of pregnancy.

You are more likely to develop gestational diabetes if you have any of the following risk factors:

• your body mass index (BMI) is 30 or higher;
• you have previously given birth to a baby weighing 4.5 kg (10 lbs) or more;
• you have had gestational diabetes before;
• you have a parent, brother or sister with diabetes;
• your family origin is South Asian, Chinese, African-Caribbean or Middle Eastern.

If you have any of the above risk factors, you should be offered a glucose test. This may be a simple blood test in early pregnancy and/or a glucose tolerance test (GTT) when you are between 24 and 28 weeks pregnant.

If you have had gestational diabetes in a previous pregnancy, you will be offered either a kit to check your own blood glucose levels or a GTT in early pregnancy. If these are normal, you will be offered a GTT again at 24–28 weeks.

During your routine pregnancy care, your urine is tested for glucose. If glucose is present, then your healthcare team may recommend that you have a GTT.

Most women who develop gestational diabetes have healthy pregnancies and babies. However, if gestational diabetes is not diagnosed early or treated, it can cause serious problems, and you may have higher chances of having an induced labour or a caesarean birth. If diagnosed with gestational diabetes, you will be under the care of a specialist healthcare team and will be advised to have your baby in a hospital with a consultant-led maternity unit and a neonatal unit.

When can medical negligence claims arise in antenatal midwifery care?

Most pregnancies progress without complications. Where they do arise, close monitoring normally ensures that no harm comes to mum or baby. If, however, you are concerned that you or your baby have suffered an injury as a result of substandard antenatal care, you may wish to consider making a complaint to the hospital trust or seeking legal advice regarding a potential medical negligence claim.

Areas where medical negligence claims may arise in antenatal care include:

• missed or incomplete risk assessment at booking;
• growth surveillance concerns: not measuring, not plotting, or not escalating;
• reduced fetal movements: reassurance without appropriate assessment;
• gestational diabetes: failure to offer testing or act on risk factors/results;
• communication, documentation and continuity issues;
• lack of informed decision‑making and consent.

Most antenatal journeys are positive, and midwives play an essential role in providing safe, compassionate care and timely escalation when needed. If something does not feel right, whether it is changes to symptoms, movements, or simply feeling you have not been heard, you are entitled to ask questions and seek support and further assessment.

If you have concerns about your antenatal treatment, our specialist maternity care team can offer a confidential, no‑obligation consultation. We will listen, explain practical next steps, and advise whether an investigation is likely to be helpful to you.

[This article has been written with the help of the Royal College of Obstetricians and Gynaecologists’ patient information guides on pregnancy.  https://www.rcog.org.uk/for-the-public/browse-our-patient-information/]