Routine Prenatal Care

Key Messages

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These are the main health messages that should be conveyed to all future and new parents. They have been written in the second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic.

A checkup before conceiving will help you prepare for pregnancy. Early and regular prenatal care will help you have a healthy pregnancy and baby.

A medical checkup before you are pregnant can help ensure you are in good health and are making healthy choices that support a healthy pregnancy. A checkup before you are pregnant can also screen for any illnesses or conditions that could affect your pregnancy.
The main goal of prenatal care is to ensure a healthy mother and baby. Regular prenatal care:

  • Supports healthy pregnancy.
  • Prevents and identifies health concerns.
  • Provides the opportunity to ask questions.
  • Provides links to helpful community services.

Ideally, prenatal care begins as soon as you learn you are pregnant. However, prenatal care at any point in pregnancy is good for your health and the health of your growing baby. Early confirmation of pregnancy is important because it allows for early prenatal care.

Prenatal care is delivered by different health care providers, including obstetricians, family doctors, Registered Midwives, and Nurse Practitioners.

Routine prenatal care delivered by any of these health care providers is covered by the Ontario Health Insurance Plan (OHIP). The availability of prenatal health care providers depends on where a mother lives and the health status of the mother and baby. In addition to a primary health care provider, health care professionals such as Registered Nurses, Registered Dietitians, and others may also be involved in providing prenatal care.
It is important that you have a primary health care provider you trust and feel comfortable with.

Routine prenatal care visits with your health care provider will help monitor your health and the health of your baby.

Routine prenatal care visits are scheduled at least monthly and usually include checking:

  • Your weight.
  • Your blood pressure.
  • Your urine (for protein and sugar).
  • Baby’s growth.
  • Baby’s position (once able to determine).
  • Baby’s heart rate (once able to detect).

Each time you visit your health care provider, you can ask questions about your pregnancy. Your health care provider or another member of the health care team can provide you with information to help you during each stage of your pregnancy. A visit to your dentist is an important part of your prenatal care to help reduce the risk of cavities and bleeding gums.

Throughout your pregnancy, you may be offered a variety of different medical and laboratory tests. This could include:

  • Diagnostic ultrasound.
  • Blood tests.
  • Urine tests.
  • Prenatal screening tests, including genetic screening.
  • Vaginal cultures or swabs.
  • Glucose screening.
  • Group B Streptococcus (GBS) screening.
  • Other tests as needed.

Prenatal education programs are an important part of your care and support during pregnancy.

Prenatal education can be a series of classes, either online or in-person, provided for pregnant women, their partner, and/or support people.
Prenatal education can:

  • Provide the information and skills you need to have a healthy pregnancy and baby.
  • Promote a positive birthing experience.
  • Prepare you for parenting.
  • Prepare you for breastfeeding.
  • Enhance communication between partners about pregnancy and parenting.

Learn more about how to access routine prenatal care.

The following may help you locate a health care provider in your area. More information can be found in the Resources and Links section.

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Supporting Evidence

The supporting evidence is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with new and expectant families; it is meant to provide the background information and evidence for the key messages.

About Routine Prenatal Care

The information in this document is not meant to indicate to health care providers how to provide routine prenatal care. Instead, it is intended to provide background information for prenatal education providers so that they will be able to explain to their clients what to expect as part of their routine prenatal care.

Defining routine prenatal care

Routine prenatal care (also known as antenatal care) is regular, standardized care that helps to identify and treat complications and promote health and wellness during pregnancy. Ontario physicians, midwives, and Nurse Practitioners use the standardized Ontario Perinatal Record (OPR) forms to guide and record prenatal care. The OPR is also a communication tool that documents the course of pregnancy and identifies risk areas and care plans in a standardized format.1

National and provincial statistics

According to the Better Outcomes Registry and Network (BORN) “ in 2011-2012 , 86% of women attended an antenatal visit with a health care professional in their first trimester.” 2 This percentage has remained similar since 2007.2 In Canada, 97 percent of women with children aged birth to eleven months had received prenatal care in 2001.3 On average, pregnant women in Ontario attended seven to eleven prenatal appointments throughout their pregnancy.4 In Ontario, from 1993 to 2004, there has been a steady increase of babies being born under the care of midwives, and the involvement of general practitioners/family physicians providing prenatal care and delivering babies has decreased.4

Who provides prenatal care?

A pregnant woman has a choice of health care providers. It is important that a pregnant woman selects a health care provider who best suits her needs and with whom she feels comfortable to ask questions and raise concerns. A health care provider is someone who provides health services, such as an obstetrician, family doctor, Registered Midwife, or Nurse Practitioner.

In Ontario in 2011 – 2012, obstetricians attended 84.7 percent of births, family doctors attended 8.6 percent of births, and midwives attended 5.2 percent of births.2 The table below summarizes the care provided by various health care providers and the location of care.

Table 1: Who provides prenatal care?

Health care provider Care provided Location of care
  • Prenatal care for low and at risk clients.
  • Labour and birth care.
  • Caesarean section surgery (as required).
  • Postnatal care for mother.
  • Office.
  • Hospital.
Family doctor
  • Prenatal care for low-risk clients.
  • May share care with obstetrician.
  • May provide labour and birth care.
  • May provide caesarean care especially in rural areas.
  • Postnatal care for mother and baby.
  • Office.
  • Hospital.
Nurse Practitioner
  • Prenatal care for low-risk clients.
  • Postnatal care for mother and baby.
  • Office.
  • Hospital.
  • Prenatal care for low-risk clients.
  • Labour and birth care for low-risk clients.
  • Postnatal care for mother and baby.
  • Office.
  • Hospital.
  • Birthing centres.
  • Home Births.
Aboriginal midwife
  • Prenatal care for Aboriginal women.
  • Labour and birth care for Aboriginal women.
  • Postnatal care for Aboriginal women and children.
  • As above, mainly limited to within Aboriginal communities.5

Prenatal education

Prenatal education is designed to provide participants with the knowledge and skills needed to improve pregnancy and birth outcomes, and helps prepare participants for early parenting. Prenatal education can be presented both in-person and online.

Within Ontario, approximately one in four women participated in prenatal education classes during their pregnancy.6 Several groups of women have been found to be less likely to receive prenatal education, including: Aboriginal women, single mothers, visible minorities, mothers without a high school diploma, and mothers who had lower incomes and were unemployed.6

Many benefits have been associated with prenatal education, including improved maternal mental health, increased mental preparation for childbirth among pregnant women, decreased use of epidural anesthesia during childbirth, increased likelihood of arriving at the hospital in active labour, increased breastfeeding initiation and duration, and greater satisfaction with the couple and parent-infant relationships following birth.7

Who is at Risk?

Aboriginal women

“Aboriginal populations, both on and off reserves, experience high levels of poverty, chronic disease, disability, sexual abuse, suicide, Fetal Alcohol Spectrum Disorder, homelessness, family violence, and other social issues. Historical factors continue to have an impact on Aboriginal communities, families, children, and youth, including choices and consequences around reproductive health and parenting. The loss of traditional values, language, family and community kinship due to colonization, residential schools, and other historical events has seriously affected the physical, emotional, mental, and spiritual health of Aboriginal people in Canada.”8 As a result, Aboriginal women are at an increased risk for pregnancy complications, including preterm labour, low-birth-weight babies, and increased neonatal and infant mortality.9

In addition to what may be seen as standard prenatal medical care, service providers can benefit from information about the impact of historical trauma and care that is inclusive of traditional medicines and practices. “Historical trauma is cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma.”10 Including traditional methods of health and healing with mainstream health services can be an effective way to assist expectant Aboriginal parents.11

Adolescent mothers

Pregnant adolescents, especially those under 17 years of age have a greater risk of many pregnancy complications, including preterm birth, low birth weight, pregnancy-induced hypertension, anemia, and neonatal and infant mortality.12 Adolescent mothers may be at increased risk due to biological and social factors, including poor nutritional status, low pre-pregnancy weight and height, poor pregnancy weight gain, increased tobacco and substance use, increased rates of violent relationships, and mental health concerns.12,13,14

Intensive, nonjudgmental programming that works with adolescent mothers has been shown to have positive effects on parenting and parent-child interactions as well as growth and development.15

Homeless or underhoused women

The lack of stable or adequate housing can have significant health implications during pregnancy. Poor housing places women at higher risk for chronic and infectious diseases and premature death. Women are often homeless because of a history of physical, sexual, or emotional abuse.16 Homeless or underhoused pregnant women may experience more barriers to access prenatal care and services.


Upon arrival in Canada, many immigrant and refugee women face challenges in adjusting to their new environment. These may include language, cultural, and religious barriers; employment challenges; and assuming roles that may differ from their traditional roles.17 The National Organization of Immigrant and Visible Minority Women of Canada (NOIVMWC) notes that the main issues faced by immigrant and refugee women are:

  • Isolation from mainstream society.
  • Differing cultural values, belief systems, and practices that create serious barriers for women in their understanding, access, and interaction with the health care system.
  • Lack of access to culturally-sensitive health care services and the inability of large numbers of immigrant and refugee women to speak English or French.
  • Compromised mental health due to the stigmatization of their immigration and socioeconomic status; racism; and general marginalization.18

When arriving in Ontario, new immigrants can receive medical services, but they are not always free. During the first three months in Ontario, immigrants are not covered under the Ontario Health Insurance Plan (OHIP). If at all possible, securing private health care coverage before they arrive in Ontario is ideal. Once in Ontario, if they plan to purchase private health coverage, they must do so during the first five days after arrival and pay for it. If new immigrants do not have private insurance during the first three months, they will need to pay for any services that are required. Details about this are available through Ontario Council of Agencies Serving Immigrants (OCASI). For refugees, before OHIP begins, they can get emergency and essential health services through the Interim Federal Health Program.

Midwifery services throughout pregnancy, birth, and postnatal up to six weeks are provided free to residents of Ontario, whether or not they have OHIP. However, without OHIP some medical services that might be needed while receiving care (e.g., hospital stay, lab tests, ambulance, etc.) would not be paid for.

Women over 35 years of age

While most women of advanced maternal age (i.e., age 35 and older) will have a healthy pregnancy and baby, age can be a risk factor for some complications in pregnancy and the postpartum period. Women over age 35 are at higher risk for the following:

  • A multiple birth.
  • A baby with a chromosome difference.
  • Pregnancy loss.
  • Gestational diabetes.
  • Hypertension.
  • Preterm birth.19

Women living in poverty

Poverty increases a woman’s risk for poor nutrition, precarious housing, and difficulty accessing health care which in turn can lead to pregnancy complications, including preterm labour, low birth weight, and increased neonatal and infant mortality.20

Women with pre-existing medical conditions

There are many chronic health conditions that may put a woman and baby at increased risk of complications, including hypertension, cardiovascular disease, diabetes, obesity, addictions/substance use, and mental health concerns. These women will require additional medical care based on their medical history.

Preconception Care

A complete discussion of preconception care and associated key messages can be found in the Health before Pregnancy file.

Benefits of preconception care

Pregnancy outcomes are influenced by many factors, including preconception health, healthy behaviours, and medical history. With approximately 50 percent of pregnancies being unplanned, by the time many women know they are pregnant it may be too late to prevent some birth defects (e.g., neural tube defects (NTDs)).21 Health care providers have been identified as the preferred source of preconception information for people of reproductive age.23 Research has shown that, in Canada, fewer than 60 percent of obstetricians and family physicians discussed the use of folic acid supplementation (in order to prevent NTDs) with women prior to conception. Substance use (i.e., alcohol, tobacco, drugs) prior to conception is also associated with poor perinatal outcomes. However, fewer than 50 percent of health care providers in Canada discussed smoking, alcohol use, or addiction history with women of childbearing age.22

Population trends suggest that women are postponing childbearing until later in life when fertility changes. Research suggests that many do so without sufficient information about possible consequences such as difficulties conceiving and pregnancy complications, such as preterm birth.19

The absence of national preconception guidelines in Canada results in inconsistent and incomplete preconception care services. The Ontario Public Health Association (OPHA) has written a position paper on preconception health entitled SHIFT-Enhancing the Health of Ontarians: A Call to Action for Preconception Health Promotion & Care.

Men and women should start planning at least three to six months before pregnancy to improve their health. Being healthy before pregnancy improves the chances of:

  • Making healthy sperm and eggs.
  • Getting pregnant.
  • Having a healthy pregnancy.
  • Giving a future baby a healthy start in life.23

For women who have already had a baby, spacing between pregnancies (interconception) is also an important discussion topic with a minimum of 18 months between pregnancies. Planned timed between pregnancies can be used to provide additional interventions for those who have had adverse pregnancy outcome.24

Topics discussed as part of preconception care

  • Alcohol use.
  • Environmental hazards.
  • Folic acid.
  • Immunization.
  • Maternal weight.
  • Medical and family history.
  • Medications, including over-the-counter and herbal products.
  • Mental health.
  • Nutrition.
  • Physical activity.
  • Tobacco use.
  • Readiness for pregnancy and parenting (e.g., financial, emotional).
  • Recreational/street drug use including abuse of prescription medication.
  • Relationships.25

Prenatal Care Visits

Frequency of prenatal visits

For expectant women with no identifiable risks, the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends a prenatal visit:

  • Every four weeks until 30 weeks’ gestation.
  • Every two weeks from 32 to 36 weeks’ gestation.
  • Once a week from 37 weeks’ gestation until birth.

A woman may need extra medical attention or health care advice from her health care provider if she:

  • Is underweight or overweight.
  • Has a history of preterm labour or previous pregnancy concerns.
  • Has diabetes, high blood pressure, or other medical conditions.
  • Has a family history of genetic conditions.
  • Is over 35 years of age.
  • Is carrying more than one baby.
  • Has had uterine surgery (e.g., caesarean section).
  • Uses alcohol, cigarettes, drugs, or other substances.
  • Is being abused, or there is a potential for abuse.
  • Is dealing with depression or other mental health 26

Routine monitoring at each appointment

Weight gain

The ideal amount of weight to gain during pregnancy is based on a woman’s pre-pregnant body mass index (BMI) as well as the number of fetuses (BMI = weight (kg)/height (m)2). Evidence shows that women who gain the recommended amount of weight during pregnancy have fewer complications, such as caesarean section, gestational hypertension, and low or high birth weight.27,28

Table 2: Recommended weight gain for a singleton pregnancy

The table below indicates the recommended weight gain during pregnancy based on a woman’s BMI prior to pregnancy.29

Pre-pregnancy BMI Mean rate of weight gain in the second and third trimester Recommended total weight gain
kg/m2 kg/week lb/week kg lbs
BMI < 18.5 0.5 1 12.5 – 18.0 28 – 40
BMI 18.5 – 24.9 0.4 1 11.5 – 16.0 25 – 35
BMI 25.0 – 29.9 0.3 0.6 7.0 – 11.5 15 – 25
BMI ≥ 30.0 0.2 0.5 5 – 9 11 – 20

Blood pressure

Blood pressure is monitored frequently during pregnancy due to the changes in blood volume and cardiac output during pregnancy. Hypertensive disorders of pregnancy are classified as pre-existing hypertension (occurring before 20 weeks’ gestation/prior to pregnancy); gestational hypertension (occurring after 20 weeks’ gestation and having a diastolic blood pressure over 90); or pre-eclampsia. Hypertension is associated with significant maternal and fetal health concerns. Pre-eclampsia is defined as gestational or pre-existing hypertension plus proteinuria and/or one or more adverse conditions. Adverse conditions may include headache, visual symptoms, right upper-quadrant or epigastric pain, nausea and vomiting, changes in blood values such as elevated liver enzymes, intrauterine growth restriction (IUGR), and ultrasound Doppler flow changes. Edema is commonly seen in pregnancy but is not a diagnostic criterion for pre-eclampsia. If a woman develops high blood pressure, she will be followed closely.

Medication to lower blood pressure may be needed if blood pressure becomes very high. Intravenous magnesium sulphate may also be given to reduce the chance of seizure. A woman may also be induced early as the only way to begin to curb the problem is birth of the baby and the placenta.

A variation on hypertension is HELLP Syndrome, which presents as hemolysis, elevated liver enzymes, and low platelet count.

All types of hypertension in pregnancy will need to be assessed, monitored, and treated (when indicated) to avoid complications. Maternal complications that are concerning, include stroke (if the blood pressure is too high), placental abruption, renal failure, or seizure (called eclampsia). Fetal complications include decreased amniotic fluid, growth restriction, or inability to cope with labour.30

Urine testing

Urine dipstick testing for sugar and protein will be done at every visit during pregnancy as a way of screening for diabetes, pre-eclampsia, and urinary tract infection (UTI). A midstream urine sample for culture and sensitivity is done in each trimester for women with known history of UTIs. At least one routine urine culture should be done during pregnancy for women with no history of UTIs. Urinary tract infections can lead to preterm labour; therefore, all UTIs need to be treated even if the mother is asymptomatic.1,26

Fetal growth

Measurement from symphysis pubis to top of fundus (fundal height) is done and plotted on a graph in the antenatal record. Fundal height, measured in centimeters, is generally defined as the distance from the pubic bone to the top of the uterus. After the first 16 weeks of a singleton pregnancy, the fundal height measurement often matches the number of weeks pregnant, (e.g., at 27 weeks pregnant, the fundal height expected would be about 27 centimeters). If a woman’s measurements are not following the expected curve on the graph, further testing (ultrasound) may be required as it may be indicative of:

  • Slow fetal growth (intrauterine growth restriction).
  • Rapid fetal growth.
  • Too little amniotic fluid (oligohydramnios).
  • Too much amniotic fluid (polyhydramnios).
  • Multiple gestation.
  • Uterine fibroids.31
Fetal heart

Between 10 to 12 weeks’ gestation, a fetal heart rate may be heard by a hand-held Doppler or seen on a transabdominal ultrasound. In the second and third trimester, the fetal heart rate may be heard using a fetoscope or stethoscope. A normal fetal heart rate is between 110 to 160 beats per minute.32

Routine prenatal care: 0 – 20 weeks’ gestation

Confirmation of pregnancy and due date calculation

A first trimester ultrasound should be offered, ideally between 8 and 14 weeks, to all women, as it is a more accurate assessment of gestational age than the last menstrual period. The accurate determination of gestational age is required for many aspects of prenatal care. There is now emerging data that even a few days of inaccuracy can affect things such as the performance of maternal serum screening. When performed with quality and precision, ultrasound alone is more accurate than a confirmed menstrual date for determining gestational age in the first and second trimesters (≤ 23 weeks).33 Ideally, every pregnant woman should be offered a first trimester dating ultrasound; however, if the availability of obstetrical ultrasound is limited, it is reasonable to use a second trimester scan to assess gestational age. Ultrasound can be used for the following:

  • To determine location of the pregnancy – uterine (in the uterus) or ectopic/tubal (in the fallopian tubes).
  • To determine age of fetus and a correct due date.
  • To screen for abnormalities in the fetus.
  • To determine the location and condition of the placenta.
  • To confirm suspected multiple pregnancies.
  • To determine the amount of amniotic fluid.34
Non-medical use of ultrasound

Both Health Canada and the Food and Drug Administration (FDA) in the United States have recommended against commercial and entertainment ultrasound.36 The standards of care around technical safeguards, infection control, maintenance of equipment, and operator training/qualifications cannot be guaranteed; therefore, the safety cannot be assured.

Health Canada recommends that ultrasound should not be used:

  • To take a picture of the fetus solely for non-medical reasons.
  • To learn the sex of the fetus solely for non-medical reasons.
  • For commercial purposes, such as the display of pictures or videos of a fetus at tradeshows.36,37

Medical and laboratory tests

Some of the following tests are universal and some are offered to women based on their individual situation/risk factors.

Blood work
  • Blood type and Rh factor.

Identification of a mother’s blood type is required in case of a required blood transfusion and to determine the risk of blood incompatibility with the baby’s blood. Blood type is further assessed to determine if mother is Rh positive or Rh negative. Rh negative means the mother does not have the Rh factor in her blood (15 percent of mothers are Rh negative).55 If a mother is Rh negative, an injection of Rh immunoglobulin such as WinRho (a blood product that protects baby from the mother’s antibodies) will be given between 28 and 32 weeks of gestation and again within 72 hours after birth (if the baby’s blood type is Rh positive).38

There are other times an Rh-negative woman may require the Rh immunoglobulin, including:

  • All forms of abortions (spontaneous, missed, and induced abortions; ectopic and molar pregnancies).
  • Antepartum hemorrhage (first trimester bleeding, placental abruption, and placenta previa).
  • Invasive fetal procedures (amniocentesis and chorionic villous sampling (CVS)).
  • Abdominal trauma (car accident/falls).1
  • Complete blood count.

A complete blood count is a blood test that determines the concentration of red blood cells, white blood cells, and platelets. A pregnant woman with a low hemoglobin level has anemia or is at risk of having anemia, which is common in pregnancy and may require diet adjustments and/or an iron supplement or may require further testing. 39

  • Hepatitis B surface antigens.

Hepatitis B is a viral infection that causes liver inflammation and is linked with liver disease, including cirrhosis and liver cancer. The incidence of people with hepatitis B is 1 in 250. All pregnant women should be screened for hepatitis B virus. Many people are chronic carriers of hepatitis B and do not know they have it.

Risk factors for contracting hepatitis B include:

    • Receiving a blood transfusion or blood products.
    • Having had multiple sexual partners.
    • Being born in Asia or other countries where hepatitis B is endemic.
    • Using IV drugs and sharing needles.
    • Handling blood and blood products.

Mothers with hepatitis B may not have any symptoms. If undetected in the mother, the baby will have a 50 percent chance of becoming infected and becoming a chronic carrier. Babies born to mothers who test positive for hepatitis B can receive both the hepatitis B immunoglobulin and the hepatitis B vaccine shortly after birth. 40

  • Human immunodeficiency virus (HIV).

HIV is found in an infected person’s blood, vaginal fluids, breastmilk, and semen. This virus affects the mother’s or baby’s immune system and can lead to Acquired Immunodeficiency Syndrome (AIDS). The onset of symptoms may take more than five years; consequently, many mothers may not know that they have contracted this disease.

A mother may transmit this virus in utero, during childbirth, or while breastfeeding. If a mother is HIV positive, medication and treatments can help to decrease the risk of transmission to the baby. Babies born to confirmed HIV-positive mothers can also receive treatment for the first six weeks of life that will greatly reduce the transmission rate.

An HIV-positive pregnant woman who is untreated has a one-in-four chance of passing the infection to her baby. However, the risk of transmission can be reduced to less than one percent if the expectant mother takes antiretroviral drugs during pregnancy and at birth and if the baby receives treatment after birth.41 Therefore, it is important to be tested for HIV before or during pregnancy. In Canada, about 2 in 1,000 pregnant women are HIV positive. 41

All pregnant women in Canada are offered HIV testing; however, women must legally consent and agree to be tested. Women should be informed about the types of testing available (e.g., nominal, non-nominal, and anonymous) in order to make an informed decision about HIV testing. In Ontario, HIV testing is not routine (i.e., women have to opt in or choose to have the testing done prenatally). Public health units or the Ontario AIDS Hotline (1‐800‐668‐2437) will provide information about anonymous testing and counselling for HIV. Pregnant women who are HIV positive will be followed during their pregnancy by a specialized interdisciplinary team.

  • Syphilis.

All pregnant women should be tested for syphilis (a sexually-transmitted infection). Early treatment with antibiotics will decrease the risk of neonatal complications. If left untreated syphilis may lead to preterm labour and health complications for the baby.1

  • Rubella (German measles).

Rubella (German measles) is a viral infection that can be very dangerous for the fetus and is most dangerous early in pregnancy. If infection occurs during the first trimester, there is an 85 percent chance that the baby will also be infected.40 Infection in an unborn baby can lead to deafness, cataracts, cardiac defects, intellectual deficits, bone damage, and enlargement of the liver and spleen. Rubella immunity should be determined prior to conceiving or as soon as pregnancy is confirmed. The combined measles-mumps-rubella (MMR) vaccine is a live-attenuated vaccine; therefore, it is not given during pregnancy due to a theoretical risk.40 Women should wait at least four weeks after getting the vaccine before trying to conceive. For pregnant women without documented immunity, vaccination should be given after birth.

  • Varicella (chicken pox).

Many women have acquired natural immunity through exposure to varicella earlier in life or through immunization. Although rare, the virus can be transmitted to the baby via the placenta if contracted by the pregnant woman during the first trimester. Varicella can cause serious problems for an unborn baby. Ideally, a pregnant woman would be tested prior to pregnancy to make sure she is immune and if not, she could be vaccinated. If a woman is vaccinated for varicella prior to pregnancy, she should wait four weeks before trying to conceive, as it is a live vaccine. Pregnant woman should not be vaccinated until following birth.40

  • Parvovirus B19 (fifth disease).

Exposure to the parvovirus B19, which causes fifth disease, rarely causes any serious complications for pregnant woman or baby. Fifty percent of women are already immune and these women, and their babies, are protected from infection and illness.42 However, sometimes parvovirus B19 infection will cause the unborn baby to have severe anemia, and the woman may have a miscarriage. This occurs in less than five percent of all pregnant women who are infected with parvovirus B19 and occurs more commonly during the first half of pregnancy. There is no vaccine for fifth disease. A blood test will indicate if a woman has immunity.42

Prenatal genetic screening

Prenatal screening is offered early in pregnancy. The decision to screen, and take action based on the results, should be determined by the pregnant woman after careful and informed consideration of the potential risks, adverse effects, and possible benefits. Consultation with a health care provider is a critical step in this process. While screening may bring reassurance for some women, for others it can bring anxiety and uncertainty.

A woman needs to fully understand what a positive screen means as well as what other tests she will be offered in the event of a positive screen. Some questions that a pregnant woman may wish to consider before having screening include:

  • If the screen results are positive, will I want further testing?
  • Do I want to know if my baby has a chromosomal anomaly or neural tube defect?
  • If the screen results are positive, how will this information affect my feelings toward the pregnancy?
  • If a diagnostic test indicated that the baby had a serious condition, would knowing help me make decisions regarding the pregnancy?43

All pregnant women have a very small chance of having a baby with a chromosomal anomaly or a neural tube defect. Prenatal screening involves a blood test and/or nuchal translucency (NT) ultrasound at 11 weeks of pregnancy. Maternal age is one factor used to calculate a baby’s risk of chromosome anomalies. Screening tests give a better estimate of risk than age alone, for those aged 35 to 39.43 A screening result is more likely to be positive with increasing maternal age. 44

Couples should be questioned about a family history of genetic disorders, a previous fetus or child who was affected by a genetic disorder, or a history of recurrent miscarriage. Genetic counselling should be offered to couples who did not receive it before conception. Expectant couples who belong to an ethnic group with an increased incidence of a recessive condition should be offered disease-specific screening as early in pregnancy as possible, if they were not tested before conception.39

Prenatal screening tests are not diagnostic tests and only indicate the chance of having a baby with certain abnormalities. Depending on the results, a women’s health care provider may recommend diagnostic tests such as further ultrasound examination, chorionic villus sampling (CVS), amniocentesis, or non-invasive prenatal testing (NIPT) and consultation with a genetic counsellor.

Prenatal screening tests determine the chances of having a baby having:

  • Trisomy 21 (Down syndrome).
  • Trisomy 18.
  • Open neural tube defects.

Tests do not screen for all chromosome abnormalities or birth defects.

There are different prenatal screening tests available depending on how far along a woman is in her pregnancy. Not all tests are available in all areas. It is important for women to talk with their health care provider about recommended/available testing.

Early prenatal screening

If a woman is 14 weeks pregnant or earlier, she may have several options available:

  • First Trimester Screening (FTS).

First Trimester Screening involves a blood test and nuchal translucency ultrasound, to determine increased risk of Down syndrome. The tests can be performed on the same day and are done between 11 and 14 weeks of pregnancy. The results will be received between 12 and 15 weeks of pregnancy. FTS is 80 percent to 85 percent accurate and has a false positive rate of three percent to nine percent.43

  • Integrated Prenatal Screening (IPS).

Integrated Prenatal Screening is used to determine risks of trisomy 21 (Down syndrome), trisomy 18, or neural tube defects. IPS is a two-step process. The first step involves a blood test and nuchal translucency ultrasound between 11 and 14 weeks of pregnancy. A second blood test is done between 15 and 20 weeks of pregnancy. The results will be received between 16 and 21 weeks of pregnancy. IPS is 85 percent to 90 percent accurate and has a false positive rate of two percent to nine percent.43

  • Serum Integrated Prenatal Screening (SIPS).

Serum Integrated Prenatal Screening is a series of blood tests used to determine increased risk of trisomy 21 (Down syndrome), trisomy 18, or neural tube defects. SIPS does not involve a nuchal translucency test and as a result is a preferred method when nuchal translucency is not available. SIPS involves a blood test between 11 and 14 weeks of pregnancy and another between 15 and 20 weeks of pregnancy. The results will be received between 16 and 21 weeks. SIPS is 80 percent to 85 percent accurate and has a false positive rate of two percent to seven percent.44

Nuchal translucency ultrasound is available in most mid-sized or larger cities. If a woman lives in an area where this specialized ultrasound is not available, she can still have SIPS.

If a woman is more than 14 weeks pregnant and wishes to have prenatal screening she can have triple or quadruple prenatal screening. Quadruple prenatal screening has replaced triple screening in most areas because it is more accurate. A blood test is taken between 15 and 20 weeks of pregnancy, and results will be received between 16 and 21 weeks of pregnancy. Quadruple screening is 75 percent to 85 percent accurate and has a false positive rate of 5 percent to 10 percent.44

A woman who will be 35 years of age or over at her due date, she can choose to go directly to diagnostic testing such as CVS and amniocentesis.

Pap test/sexually transmitted infection screening (STI)

A Pap smear to check for cervical dysplasia is a normal component of well health care and for low-risk women is performed every three years. If a pre-pregnant Pap smear was done within this time period, it does not need to be done as part of prenatal care.1 A pelvic exam to screen for STIs will be done in first trimester and may be done again in the third trimester depending on individual risk factors.45

Discussion topics

Abuse assessment

Pregnancy is a time when abuse can begin or can become more severe. The prevalence of abuse during pregnancy in Canada is between six percent and eight percent, although the percentage may be higher due to under reporting.46,47 All women, regardless of socioeconomic status, race, sexual orientation, age, ethnicity, or health status, are at risk for abuse. Abuse rates among pregnant and adolescent women appear to be greater. Women who are immigrants or refugees, lesbians, women of colour, Aboriginal, and women who have disabilities may experience abuse differently and may have more barriers to disclosure.48 Women abused during pregnancy are more likely to be depressed, suicidal, and experience pregnancy complications and poor outcomes, including maternal and fetal death.46 If a woman discloses abuse, appropriate referrals may help mitigate the risk and provide necessary support.

For more information, see the Abuse file.


There is no safe amount of alcohol consumption during pregnancy. When alcohol is consumed in pregnancy, it is known to cause birth defects and brain damage.25 For more information, see the Alcohol file.


Breastfeeding is the normal and unequalled method of feeding for a baby and for mother. The decision to breastfeed is most often made before pregnancy or during the first trimester. Education by a breastfeeding-supportive health care provider regarding the importance of breastfeeding has been shown to positively influence breastfeeding rates.49,58 For more information, see the Breastfeeding file.

Hot tubs/saunas

When a pregnant woman’s core body temperature is raised (hyperthermia), it can have a negative impact on the fetus, particularly during the early weeks of organ development. Hyperthermia, during the first weeks of fetal development, has been linked to neural tube defects. There is no firmly-established temperature or length of exposure that is considered safe during pregnancy; however, health education and caution are encouraged.26


Some diseases can cause complications during pregnancy, including birth defects. Vaccination at least three months before pregnancy provides immunity to a mother and baby and decreases the chance of spreading disease. A mother’s immunity can protect her baby during pregnancy and often for the baby’s first 6 to 12 months of life. Most types of vaccines are safe during pregnancy. 50,40 These include passive vaccines and some active vaccines. Live-attenuated vaccines are not given if a patient knows she is pregnant because there is a theoretical risk to her baby. However, in cases where live-attenuated vaccines have been given to women who did not know they were pregnant, there has been no evidence of adverse outcomes.40

  • Seasonal and H1N1 influenza vaccines.
    Influenza, or flu, is a highly-contagious acute respiratory virus. The seasonal flu vaccine is safe for pregnant women and is recommended for those who will be pregnant during flu season. Being immunized will also help protect the baby through his or her first few months of life. Pregnant woman especially those in their second and third trimesters are at increased risk for hospitalization, morbidity and mortality with an H1N1 infection and therefore vaccination is recommended when vaccine is available. 40
  • Tetanus, diphtheria, and pertussis.
    All pregnant women should be offered the diphtheria and tetanus toxoids and acellular pertussis vaccine during the second or third trimester, preferably between 21 and 32 weeks gestation, during
    every pregnancy, irrespective of their immunization history 40
  • Measles, mumps, and rubella.
    This vaccine is not recommended during pregnancy as it is a live-attenuated vaccine. Please see the blood work section, part of “Medical and laboratory tests” above.40
  • Varicella (chicken pox).
    This vaccine is not recommended during pregnancy as it is a live-attenuated vaccine. Please see the blood work section, part of “Medical and laboratory tests above.40
  • Other vaccines.
    Special circumstances might arise during pregnancy when other vaccinations are necessary such as when the woman needs to travel abroad. In some parts of the world, vaccine-preventable diseases such as polio and tuberculosis are a serious concern.40
  • Breastfeeding and immunization.
    Most vaccines are safe for women who are breastfeeding.40

Ideally, a woman would not be on any prescription medication while pregnant. However, medications may need to be taken if the benefits of being on the medication outweigh the risks to the mother and baby. The decision whether or not to take a prescription medication in pregnancy is an informed decision made by a woman in consultation with her health care provider. Ideally, this discussion would happen prior to pregnancy.

For more information, see the Medications & Drugs file.

Mental health

It is important to inquire about a woman’s mental health in pregnancy. Occasional, minor mood swings, unusual dreams, and/or scary thoughts may be experienced during pregnancy. It is only when these symptoms are prolonged and/or interfere with the woman’s day-to-day functioning that they become a concern and may affect the mother and baby’s health.51 If left untreated, depression in pregnancy will likely get worse, which can leave the woman vulnerable to becoming even more depressed following the birth of her baby. A severe postpartum depression may take longer to respond to treatment and may affect how the mother interacts with her infant.52 Appropriate support and referral can assist a woman who is having mental health challenges in pregnancy.

For more information, see the Mental Health file.

Nutrition and food safety

Eating well during pregnancy will help support optimal fetal health. Pregnant women should follow Canada’s Food Guide to Healthy Eating. There is a separate version of Canada’s Food Guide for Aboriginal populations. Pregnant women also need a prenatal vitamin that includes 0.4 – 1.0 mg of folic acid.

There are some foods that can pose a risk to the developing fetus as they can contain bacteria and parasites. Hormonal changes in pregnancy can affect the mother’s immune system making her more susceptible to listeriosis bacteria, which can cause miscarriage if contracted in the first trimester and, in later pregnancy, it can lead to an increased risk of stillbirth. Pregnant women should avoid foods such as hotdogs; unpasteurized soft and semi-soft cheeses; non-dried deli meats and meat spreads; smoked seafood and fish; and raw or uncooked meat, poultry, and fish.53

Toxoplasmosis is a parasite that is contracted by consuming raw meat, contaminated fruits and vegetables, and through handling cat litter.54 Toxoplasmosis can cause congenital anomalies, including eye, liver, and brain diseases. Pregnant women are encouraged to cook all meat and poultry, wash hands and utensils when preparing raw meat and poultry, avoid handling cats and cat litter, and wash all fruits and vegetables.54

Fish is a good source of protein and omega-3 fatty acid. However, it is also best to avoid fish that are known to have high levels of mercury as it negatively impacts fetal brain development. Examples of fish to avoid include: canned albacore tuna, shark, sword fish, marlin and orange roughy.55

For more information, see the Healthy Eating & Weight Gain file.

Occupational hazards

A pregnant woman’s job may pose risks to her pregnancy if she is exposed to chemicals or fumes, solvents, extreme temperatures, or radiation at work. Doing demanding physical work can also contribute to miscarriage or a preterm baby.1,26 If warranted, work adjustments may need to occur.
For more information, see the Safety file.

Oral health

Hormone changes in pregnancy can increase the risk of periodontal disease. Regular dental care is important. It is recommended that women have dental care early in pregnancy (optimal time is second trimester) and continue as necessary.1,26

Adjusting to pregnancy

Some pregnant women may be concerned about early pregnancy symptoms such as nausea, vomiting, and fatigue. Discussion around coping strategies may be helpful and if warranted, referral may need to occur.1,26

For more information, see the Physical Changes file.


A fetus is more sensitive than adults to x-rays as their cells divide more rapidly. If fetal cells are harmed, it could result in miscarriage, birth defects, and intrauterine growth restriction (IUGR). The teratogenic effect of x-rays is more pronounced between 8 to 15 weeks’ gestation. X-rays are generally avoided in pregnancy unless the benefits outweigh the risks.50

For more information, see the Safety file.

Recreational/street drugs

There is no safe level of recreational/street drugs in pregnancy. Women who use recreational/street drugs require specialized interventions within a harm-reduction framework. If needed, referrals to appropriate community resources may facilitate this process.

For more information, see the Medications & Drugs file.


The healthy, pregnant woman with an uncomplicated pregnancy can enjoy her sexuality and her sexual relationship throughout the pregnancy without risk to her or her baby. Protection against sexually-transmitted diseases should be practiced for all women during pregnancy. Couples should take care not to blow any air into the vagina during oral sex as a burst of air might block a blood vessel (air embolism) which could be fatal to both the woman and baby.55

Social/family support

A lack of perceived social support during pregnancy has been associated with higher levels of maternal depressive symptoms and adverse health behaviours.1 Assessment and referrals to community resources may serve to reduce these risks.


Tobacco use and exposure to second-hand smoke increases a woman’s risk of a low-birth-weight baby, preterm birth, and stillbirth. It also puts infants at risk for Sudden Infant Death Syndrome (SIDS), learning issues, and asthma.1 Health education and referrals to counselling and smoking cessation resources should be offered to women who smoke. For more information, see the Smoking file.

Routine prenatal care: 20 – 30 weeks’ gestation

Gestational Diabetes Mellitus (GDM)

Universal screening for GDM is practiced by 84 percent of Canadian obstetricians. The glucose challenge test is done during pregnancy to screen for gestational diabetes mellitus. Routine screening of women at 24 – 28 weeks of gestation may be recommended.56 If the test results are above normal, a glucose tolerance test is required to confirm gestational diabetes. Most women who have gestational diabetes give birth to healthy babies. However, without careful management, gestational diabetes can lead to various pregnancy complications, such as excess fetal growth, which might increase the risk of birth injuries or lead to a caesarean birth.56

Labour and birth plans

Women should be counselled about when to go to the hospital in labour, preterm labour signs, pain management options, possible interventions and complications, and the completion of a birth plan or birth wish list.

Routine prenatal care: 30 – 40 weeks’ gestation

Group B Streptococcus (GBS)

GBS is common bacteria, which are often found in the vagina, rectum, or bladder of women and men. These are not the same bacteria that cause strep throat. Infections from GBS are usually not serious for the non-pregnant woman and are readily treated with antibiotics. However, when a pregnant woman has an overgrowth of GBS, there is a chance the bacteria will be passed to a newborn at the time of birth. Potential maternal complications during pregnancy include preterm birth and premature rupture of membranes. Complications for infants may include preterm birth and sepsis. While GBS infection of the newborn is very rare, some babies still die as a result of complications from this infection. Pregnant women are screened for GBS at 35 – 37 weeks of gestation using vaginal and rectal swabs. If results are positive, the pregnant woman should be treated with antibiotics during labour. 57

Expectant mothers who test positive for GBS bacteria, and those for whom tests results are not available, will be treated with antibiotics when they go into labour or if their membranes rupture early.57

Kick counts

A baby’s movement can be an indicator of fetal well-being. A baby’s activity level varies through the day. To do kick counts, women are asked to observe their baby’s movements after a meal as follows:

  • Recline in a comfortable position (not flat on your back) with a clock nearby and see how long it takes to count six movements.
  • If you do not reach six movements in two hours, contact your health care provider or go to the hospital. You should feel your baby move throughout the day, every day.55

Nonstress testing (NST)

A nonstress test (NST) involves placing two belts with monitors attached to them across a pregnant woman’s abdomen. One belt will record the baby’s heart rate, and the other will record any uterine contractions. The mother will be asked to press a button when her baby moves. The baby’s movements will then be noted on the fetal heart record. Nonstress tests may be ordered by a health care provider for the following reasons:

  • A multiple pregnancy with complications.
  • An underlying medical condition, such as type 1 diabetes, high blood pressure, a blood disorder, lupus, thyroid disease, kidney disease, or heart disease.
  • A pregnancy that has extended past the due date.
  • A history of pregnancy loss.
  • A baby who has decreased fetal movements or possible fetal growth problems.
  • Too much amniotic fluid (polyhydramnios) or low amniotic fluid (oligohydramnios).
  • Results from other prenatal tests that are of concern.26

Abdominal palpation

Abdominal palpation should be used to assess fetal presentation beginning at 36 weeks’ gestation.26


When to refer

Referrals to the appropriate community resources may be beneficial for pregnant women in the following situations:

  • Women who are Aboriginal.
  • Women who are adolescents.
  • Women who experience abuse.
  • Women who are new to Canada.
  • Women who use drugs/alcohol.
  • Women who smoke.
  • Women who are living in poverty.
  • Women who are homeless.
  • Women who have mental health concerns.
  • Women who require genetic counselling.
  • Women who express a need for additional support.

Where to refer

Professionals are encouraged to refer women to specialized services that will be able to offer them the assistance they may require. Some suggestions are listed below. More resources can be found in the Resources and Links section of this file, and in the Resources and Links section of other specific topics.

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Resources & Links

Please note this is not an exhaustive list of available resources, nor should any of these resources be used in place of seeking professional advice. The resources cited throughout this resource are not necessarily endorsed by the Best Start Resource Centre or the Government of Ontario. When in doubt, professionals should contact the organization responsible for issuing a specific recommendation/practice guideline.

Professional Guidelines

Professional Associations




Prenatal Education Provider Tools

Client Resources and Handouts



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  1. Provincial Council for Maternal and Child Health (PCMCH) and The Better Outcomes Registry & Network (BORN) Ontario Perinatal Record Working Group. (2018). A User Guide to the Ontario Perinatal Record. Retrieved from
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  24. Johnson, K. A., Floyd, R. L., Humphrey, J. R., Biermann, J., Moos, M-K., Drummonds, M., … Wood, S. (2014). Action plan for the national initiative on preconception health and health care (PCHHC). Retrieved from
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  28. IOM (Institute of Medicine). (2009). Weight gain during pregnancy: Re-examining the guidelines. Washington, D.C.: National Academies Press.
  29. Institute of Medicine and National Research Council. (2009). Implementing guidelines on weight gain & pregnancy. Retrieved from:
  30. Society of Obstetricians and Gynaecologists of Canada. (2014). Diagnoses, evaluation, and management of the hypertensive disorders of pregnancy: Executive summary. Retrieved from:
  31. Mayo Clinic. (2014). What’s the significance of a fundal height measurement? Retrieved from:
  32. Institute for Clinical Systems Improvement. (2012). Health care guideline: Routine prenatal care. Retrieved from
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  48. Battaglini, A., Gravel, S., Poulin, C., Brodeur, C., Durand, D., DeBlois, S., & Centre d’excellence pour la santé des femmes – Consortium Université de Montréal. (2001). Immigration and perinatal risk. Centres of Excellence for Women’s Health Research Bulletin, 2(2), 8-9. Retrieved from
  49. Rosen, I. M., Krueger, M. V., Carney, L. M., & Graham, J. A. (2008). Prenatal breastfeeding education and breastfeeding outcomes. American journal of Maternal Child Nursing, 33(5), 315-319. doi: 10.1097/
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  53. Public Health Agency of Canada. (2012). Listeria. Retrieved from
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  55. Society of Obstetricians and Gynaecologists of Canada, & Best Start Resource Centre. (2009). Healthy beginnings giving your baby the best start from preconception to birth (4th ed.). Mississauga, ON: Wiley.
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