Routine antenatal care and risk assessment — structured oral station (12 minutes)

Opening prompt — "Outline her routine antenatal care."

Model response — lead with the structure, then the risk modification: ^[1]

• "As a parous woman she should be offered seven antenatal contacts under NICE NG201, with booking by ten weeks — she has just made it. The contacts are at booking, 16, 28, 31, 34, 36 and 40 weeks." ^[1]
• "Nulliparous women get ten, because there is more to find in a first pregnancy; pre-eclampsia and fetal growth restriction declare themselves in the third trimester, so the contacts cluster there."
• "Every contact is a fresh risk assessment — I re-screen blood pressure, urinalysis, fundal height and fetal heart, and re-tier her risk. A normal booking does not entitle her to a normal pregnancy."

Probe 1 — "She had gestational hypertension and a small baby last time. What does that change?"

• "She has at least two high-risk factors — previous hypertensive disease of pregnancy and a previous small baby — so she moves off the low-risk pathway onto a surveillance pathway."
• "I start low-dose aspirin 75 to 150 mg now, while she is under 16 weeks. The Roberge meta-analysis showed aspirin at least 100 mg started at or before 16 weeks reduced preterm pre-eclampsia with a relative risk of 0.62, with no effect on term pre-eclampsia — it modifies placentation, so timing matters."^[2]
• "I plan serial growth ultrasounds from 28 weeks with umbilical artery Doppler, because her previous baby was small and smoking raises the risk of recurrence."^[2]

Probe 2 — "What else will you offer her preventively?"

• "Folic acid 400 micrograms to 12 weeks — she is at 10 weeks so the window is closing but still worth it; the neural tube has largely closed by now. The Cochrane review shows periconceptional folate reduces neural tube defects."^[3]
• "Iodine 150 micrograms daily through pregnancy."^[1]
• "Pertussis vaccine, dTpa, between 20 and 32 weeks, and influenza vaccine at any gestation — both protect her and the infant through transplacental antibody."^[4]
• "Smoking cessation — behavioural support first; it is the single biggest modifiable risk factor for fetal growth restriction and stillbirth in her case."^[1]

Probe 3 — "She lives two hours away. How does that change her care?"

• "Distance is a structural barrier, and the women who need care most often access it least. I would not compress her contacts to save travel — I would build a model that brings care to her."
• "Midwifery-led continuity of carer is the evidence-based answer. The Cochrane meta-analysis found midwife-led continuity models reduced preterm birth and fetal loss before 24 weeks, and women were more satisfied. For an Aboriginal woman, a culturally safe continuity model — ideally Aboriginal health-worker supported — narrows the perinatal mortality gap."^[1]
• "I would offer telehealth for the routine contacts where no examination is needed, shared care with her local service, and a clear transfer plan for the third trimester when surveillance intensifies."

Probe 4 — "She asks what to do if the baby's movements slow down."

• "I tell her to contact us the same day — never to wait, never to use a home Doppler, and never to dismiss it. Reduced fetal movements are assessed with a CTG and, where indicated, a growth scan with Doppler."
• "The AFFIRM trial tested an awareness and care-bundle package and did not significantly reduce stillbirth overall, but it reaffirmed the principle: always act on reduced fetal movements, because the cost of dismissal is the stillbirth you can never undo."^[5]

Probe 5 — communication and cultural safety: "She says she finds hospitals intimidating."

Three of the eight domains are scored here. Say the words out loud. ^[1]

• Acknowledge her experience without minimising it, and ask what specifically is difficult — is it the building, the staff, the jargon, or something that happened before. ^[1]
• Offer a known carer through the pregnancy — a named midwife, ideally one with experience caring for Aboriginal women, and an Aboriginal health worker where available.
• Recognise that Aboriginal women carry a higher burden of adverse outcome and that this reflects access and services, not her. Name it as a system problem, not a patient problem.
• Ask how she would like her family involved, check whether she would like a support person or an interpreter, and use teach-back at the close.

Probe 6 — "What is the single most important principle of routine antenatal care?"

• "That risk is reassessed at every contact. The schedule, the windows and the doses are the structure — but the vigilance at each contact, the re-tiering of risk when a threshold is crossed, is the whole point. A woman booked as low-risk is low-risk until she is not, and the transition happens between visits."^[1]