Prenatal Visits

 

Your regular prenatal visits are designed to help maximize your health and the health of your baby, as well as deal with any problems that come up and answer any questions that you may have. Here’s what to expect:

Confirmation of Pregnancy Visit

This is usually the first visit you will have, shortly after you find out that you are pregnant. Your doctor will confirm that you are pregnant and try to establish a final due date, often with an ultrasound. Usually, your doctor will order your prenatal labs and deal with any current or preexisting issues, like medicines you might be taking or symptoms you may be experiencing.

Your prenatal labs consist of:

  • A CBC (complete blood count) to check for anemia and other blood disorders;
  • A blood test for syphilis, HIV, hepatitis B, and hepatitis C;
  • Your blood type and whether you have any unusual antibodies in your blood that could affect the pregnancy;
  • A rubella titer to see if you are immune to rubella;
  • A urine drug screen and urine culture.

Depending on risk factors, your doctor may add other tests, such as screening for diabetes or sickle cell anemia; and depending on your family history, you may also need screening for genetic diseases like cystic fibrosis or other familial conditions like bleeding or clotting disorders.

We will ask you a series of questions relating to your pregnancy history, medical and surgical history, family history, etc. These detailed series of questions are helpful to screen for any risk factors you may have for your pregnancy.

Some midwives or doctors will orders tests at this visit that we usually don’t recommend for most women. These include tests for thyroid function (unless you have a history of thyroid problems), vitamin D levels, and blood tests for Herpes.

New OB Visit

At this visit, we may do a general physical exam of things like your heart. Sometimes you may need a pelvic exam with a Pap smear and cultures for chlamydia and gonorrhea, if these things have not already been done. Not every woman will need a Pap smear (you don’t need one just because you’re pregnant!), so in most cases the pelvic exam may be unnecessary and we can check for chlamydia and gonorrhea in your urine. Pap smears are generally done no more often than every three years from age 21-30 and every five years after that until age 65.

We also don’t recommend a breast or pelvic exam just because you’re pregnant. So chances are, you should be able to keep your clothes on at your first visit. We will review your prenatal lab test results, go over any issues identified from your history, and talk about other pregnancy concerns you may have.

Subsequent Visits

At the first visit and every visit thereafter, we will check your weight, blood pressure, and, if possible, listen to the fetal heartbeat. This isn’t always easy before 12 weeks of pregnancy without an ultrasound. We check your urine at several visits for signs of infection and for protein, which is sometimes associated with the development of preeclampsia if you develop hypertension. You should always tell us if you are having any symptoms of a urinary tract infection, such as new onset burning with urination or urinary frequency. We will talk about any problems you are having and about things you should be looking for, etc.

Pregnancy is around 40 weeks total (which isn’t exactly nine calendar months). We will see you about once a month until 28 weeks, then every two to four weeks until about 36 weeks depending on risk factors, then weekly until you deliver. Sometimes a pelvic exam may be required, particularly if you are bleeding, leaking fluid, or have been having a lot of contractions or other labor symptoms. There’s usually not a reason to have your cervix checked at your later visits. These exams don’t predict when you might go into labor and are generally unnecessary unless you’re having labor symptoms or are planning an induction.

Some additional things about a few visits are listed below:

10-12 weeks. Some women may choose to do optional testing for fetal chromosomal abnormalities. Past and current testing strategies focus mostly on Down syndrome (trisomy 21) but as tests have improved, several other conditions can be detected as well. Currently, the preferred way of early screening is called noninvasive prenatal screening (NIPS).

NIPS is a blood test that can be performed any time after 10 weeks’ gestation and it screens for Down, Edward (trisomy 18), and Patau (trisomy 13) syndromes, as well as conditions related to an abnormal numbers of sex chromosomes like Turner syndrome (monosomy X); it can also be used to determine the baby’s sex. NIPS is now available to all patients who want it (it used to be available only to women with risk factors); it is a much better test than the previously used first trimester screening and detects more abnormalities with far fewer false-positive results.

First trimester screening is a combination of an ultrasound that looks at the thickness of the back of the baby’s neck and a blood test for two markers called PAPP-A and HCG. It was previously used to screen for Down syndrome and Edward syndrome. The test also may indicate certain types of heart defects. The test is performed between 11 and 13 weeks’ gestation and needs to be ordered in advance. Generally, this test should no longer be performed. Compared to NIPS, there is a high rate of false discoveries and unnecessary anxiety and work-ups related to those false discoveries. About 5% of patients who take the test will have a positive result; this positive result indicates an actual problem less than 1% of the time, so most positive results are false positives. What’s more, about 15% of cases of Down and Edward syndrome are missed by this test.

In contrast, NIPS detects more than 99% of these syndromes and the majority of positive results are true positives. Still, NIPS isn’t perfect. In most cases, further testing would be needed to confirm any positive result. This could be done with an amniocentesis after 15 weeks’ gestation or with chorionic villus sampling (CVS) before that time. These tests are invasive and carry some risks and so not all patients will choose to have the tests performed.

16-20 weeks. In this timeframe, usually closer to 20 weeks, all women will receive a detailed anatomic ultrasound looking at many specific parts of the fetal anatomy, including all the major organs. This helps to screen for many types of birth defects and other problems.

In the past, women were also offered a test called the quad screen during this time. This is a blood test (consisting of four markers: AFP, HCG, Estriol, and Inhibin-A) which screens for Down and Edward syndrome, as well as neural tube defects like spina bifida, abdominal wall defects like gastroschisis, and a few other problems. Like first trimester screening, this test offers no advantages over NIPS and most abnormal results are false discoveries, so generally should no longer be performed. Some doctors will order a part of this test, the AFP (alpha fetal protein), to screen for neural tube defects. We don’t recommend this as it is not evidence-based.

28 weeks. At this visit, all women whose blood type is Rh negative (such as A negative, B negative, O negative, or AB negative) will receive an injection of Anti-D antibody, commonly known as RhoGAM or Rhophylac or WinRho. This injection helps prevent mothers from forming antibodies against their babies’ blood, which might be a different blood type from their own.

Between 24 and 28 weeks’ gestation, you will have a screening test for gestational diabetes. This usually consists of drinking 50 grams of glucose and having your blood sugar checked in an hour. You don’t have to be fasting for this test, but try not to eat anything big for a couple of hours before. If you fail this test, it doesn’t mean that you have gestational diabetes but it will require you to take a three-hour test. For this test, you must be fasting. You will drink 100 grams of glucose and your blood sugar will be check four times: before you consume the drink and then at one, two, and three hours. If two or more of these glucose checks are abnormal, then you will be diagnosed with gestational diabetes.

This visit is also a good time to discuss what you might like to do for birth control after you deliver. If you are planning on having your tubes tied, it is important to let us know at this visit so we can discuss all of your options.

Also at this visit, depending on your risk factors, we may repeat your CBC to check for anemia and repeat a test for syphilis.

36-37 weeks. Almost every woman will have a swab taken of the vagina, perineum, and anus for group B Streptococcus (GBS). Around one-third of women carry this bacteria as part of their normal genital flora and it causes no problems for those who do; but, it can sometimes cause serious problems for newborns. If your test is positive, you will need to receive antibiotics in your IV when you are in labor to reduce the risk that your baby will be affected. Ideally, you will get the antibiotic at least four hours before your baby is born. Women with certain risk factors, such as a GBS positive urine culture during the pregnancy or a few other rare risks, won’t receive this test and will just be treated empirically during their labors.

You will usually start weekly visits after this 36-37 weeks’ gestation  and we will be discussing plans for your delivery.

41 weeks. If you’ve made it a week past your due date, it’s almost always time to be induced. For most women, the risks of continuing the pregnancy are greater than the risks of being induced for both the mother and the newborn.