Pregnancy

Prenatal Care - You and Your Baby

Prenatal Care

Prenatal care is the time spent with your doctor, midwife, and/or nurse that is focused on assessing and discussing the medical aspects of your pregnancy. Ideally, your prenatal care will start prior to your pregnancy with preconception care, which can help prepare you for what's to come. Starting early also gives you time to find a doctor or midwife that you will feel good about working with for the next several months.

While pregnancy is a normal state for the female body, prenatal care is helpful because it is a way to screen for complications and guide you toward your healthiest pregnancy. It is in your prenatal care appointments that you get to ask medical questions about your pregnancy and baby.

In addition to working with your doctor or midwife, you may also receive care from a variety of other people during your pregnancy.

This can include:

  • Nurses or medical assistants: They may assist your practitioner in gathering vital sign information from you or your baby. They may give injections, take blood pressure readings, cater to other basic needs you may have, and report the findings to your practitioner.
  • Nutritionist/dietician: You may need a specialized diet in pregnancy, either to help you gain weight, maintain weight, or cope with specific disorders related to nutritional requirements, including gestational diabetes.
  • Maternal fetal medicine specialist (MFM): If you have a high-risk condition, you may have an appointment or two with a high-risk practitioner. Sometimes you may even need to switch your care to this practitioner.
  • Ultrasonographer: You may or may not need to see this individual, who has special training to do ultrasounds. You may also see someone like an MFM or another specialist during your ultrasounds.

Your First Prenatal Care Appointment

Your first prenatal care appointment is scheduled when you find out that you are pregnant. Sometimes this is made fairly rapidly after you get a positive pregnancy test. Other times, you are asked to wait to come in. This may be until you have missed your second period, about eight weeks into your pregnancy.

This appointment is one of the longest appointments that you will have during your pregnancy. You will want to be prepared for this visit by knowing your basic health information, as you will be asked to give a detailed health history. You will also have additional testing and blood work done during this visit. Some offices will have you convey some information over the phone to a nurse or assistant, others collect it all in person. If time is of the essence in your scheduling due to work or other conflict, be sure to ask what your options are to do what you can beforehand.

It surprises many people, but what you and your practitioner discuss in this first visit will give him or her a lot of information about how healthy your pregnancy is likely to be. You will have a complete physical, usually including a breast exam, pap smear, and pelvic exam. You will also have a lengthy discussion about your current medications and past medical history, including any past pregnancies.

In addition to this, you will also get a basic set of screenings, which will happen at nearly every prenatal visit, including:

  • Blood work (screen for sexually transmitted diseases, blood type, etc.)
  • Blood pressure (high blood pressure is dangerous for you and your baby)
  • Weight (a healthy weight gain is important for a healthy baby)
  • Urine check for protein and/or sugar (could indicate problems with diabetes)

If you are having complications or if there is a question about something regarding your pregnancy, you may also have a transvaginal ultrasound done, though this is not something that everyone needs.

Your Due Date

One of the first things that you will be given is your due date, which is usually based on the first day of your last normal period (LMP). This date is important not just in informing you on when you can expect your baby to arrive, but in determining what care you receive when. You may also have a due date as determined by early ultrasound. This is most accurate before 10 weeks of pregnancy, but should not be used after 20 weeks. 

It is important to remember that a due date is an estimate, not the actual date that your baby will be born. The majority of babies will be born two weeks before or two weeks after the due date. Only about 3 percent to 4 percent of babies are born on their actual due date.

First Trimester Prenatal Care

If you were seen at eight weeks or before, you may actually have one more visit in your first trimester. This visit may also include discussion of prenatal genetic screenings. Depending on your age, your partner's age, and/or medical history, you may be offered blood work to screen for genetic complications including Down syndrome at this time.

 You may also be offered a special ultrasound to screen for Down syndrome, which involves measuring an area of your baby’s neck called the nuchal fold.

As for results of these tests, you will be given a number that says you have a 1 in X chance of having a baby with a specific disorder. This screening does not diagnose your baby with anything. A test is said to be positive (problematic) if your X number is lower than the number that they would expect for your age.

For example, say you have 1 in 100 chance of having a baby with a genetic concern based on your age, but after the screening, you risk is thought to be 1 in 72. This is situation where the screening put you at a higher risk category. You would be offered genetic testing, which would actually look at your baby’s chromosomes. On the other hand, if the screening gave you a 1 in 150 chance of having a baby with a genetic disorder, your risk is lower than the risk assumed given your age.

Before agreeing to the screening, you should understand:

  • What test is being done
  • Why the test is being done
  • How the test is performed
  • How the results will be given (and how to read them)
  • When to expect the results
  • Next steps, once results are available

If a test is positive, you will most likely be offered either a chorionic villus sampling (CVS) at the end of the first trimester or an amniocentesis at the beginning of the second trimester. Which test may be determined by where you live, what the specialists in your area offer, and your preferences (should you opt for further testing at all). These tests look at actual genetic material and provide a definitive diagnosis, unlike a screening.

Second Trimester Prenatal Care

If you have a low-risk pregnancy, you will have an appointment about every four weeks in this phase. You prenatal care will have a base set of procedures including:

  • Weight check
  • Blood pressure check (screening for preeclampsia and eclampsia)
  • Fetal heart tone monitoring (helps to date the pregnancy and check for viability)
  • Uterus measurement (helps to check fetal growth)
  • Urine screening

Toward the very end of the first trimester or at the beginning of your second trimester, you will hear your baby’s heartbeat for the first time using a Doppler. This is a handheld device that uses ultrasound waves to amplify the sounds for your to hear. (Don't panic if you don't hear it right away.)

If you declined genetic screening in the first trimester, you may again be offered genetic screening for Down syndrome and neural tube defects; these are tests that use a mother’s blood. This is, as in the first trimester, a screening. If you had a positive screen, you would be offered genetic testing.

Around 18 to 20 weeks, you may also be offered an anatomy ultrasound scan. While you will hear many people talk about this as a chance to find out if you are having a girl or a boy, the actual goal of it is to check on your baby’s growth and development, particularly their organs. If there are questionable findings, you may be asked to return in a few weeks to repeat the scan or to get a specifically targeted scan, such as a fetal echocardiogram (ultrasound of the baby’s heart).

The other big thing in the second trimester is that you will usually start to feel the baby move. Once this has started, your doctor or midwife will begin to ask you questions about the movement.

Third Trimester Prenatal Care

You will start with seeing your practitioner every two weeks in your third trimester. This will generally be your pattern until you hit 36 weeks, upon which time you will see your practitioner at least weekly until you give birth.

These appointments will consist of the following basics:

  • Weight check
  • Blood pressure check
  • Fetal heart tone monitoring
  • Uterus measurement
  • Urine screening
  • Blood work (to check for anemia)
  • Fetal movement check (indicator of fetal well-being)
  • Position of the baby check (screening for breech babies or a transverse lie)

At some prenatal appointments at the very end of pregnancy, you may be offered a vaginal exam. This is to assess the activity of your cervix. Your practitioner will see if your cervix is ripening (getting softer), moving forward (getting into a better position), opening (dilating), and/or effacing (thinning), and check the position of your baby in relation to your pelvis (as in how far down your baby is located, or its station). This can be helpful when deciding what type of induction of labor method to use, but it not going to give you definitive information on when labor will start. You can have no indication of change and have your baby tomorrow, or you can be four centimeters dilated and go to your regular prenatal visit in a week. Discuss with your doctor or midwife the utility of the information and determine what works best for your situation.

Gestational Diabetes Screening

You will also be offered special testing in the third trimester, usually right around 28 weeks. One screening is called the glucose screening. You will be given a special sugary drink, such as Glucola. Many people say it tastes like a really syrupy, but flat soda. You will have your blood drawn to check how your body processed the sugar in this drink. If you pass this screening, you are done. If your numbers are questionable or out of range, you will then be asked to do the three-hour version of this test, which includes four blood draws and another drink. Your blood sugar numbers need to be within range for two of the four tests to be considered a pass. If you do not pass, you are diagnosed with gestational diabetes.

If you have gestational diabetes, you will likely have more prenatal visits. Your practitioner will review information on how to check your blood sugar at home, how to eat and exercise to keep your blood sugar within a certain range, and when to call for help based on your blood sugar numbers. You may also have more ultrasounds or other testing. Some women may also require medications to help control their blood sugar.

Rh Negative Treatment With Rhogam

If your routine blood work showed that you do not have the Rh factor, a protein on the surface of red blood cells, it is recommended that you take a Rhogam shot. This is not an issue in first pregnancies, so this shot is used to protect any future babies. This shot will also be given postpartum. In the off chance that both you and your partner are Rh negative, you will not need to do the Rhogam shot.

Group B Strep Screening

Between 34 and 36 weeks, you will also be given a pelvic exam to screen for group B strep (also known as beta strep or GBS). This is a flora that is not harmful to you that can live in your vagina or rectum. If it is found, you will be offered antibiotics in labor to decrease its presence as your baby is born. This can drastically lower the risk that your baby will be colonized with group B strep, which can cause him or her to be very ill or, in rare instances, die.

Special Prenatal Care at the End of Pregnancy

As you pass your due date, particularly after week 41 of pregnancy, you may need to be seen more than once a week. In addition to a regular prenatal care visit, you may also be given special tests to check on your baby. This can include:

Using these tests and your health history, your provider will keep an eye on your baby and decide if it is safe for you to proceed to the end of your forty-second week of pregnancy, or if intervening would be more prudent. The most common intervention would be an induction of labor, where your practitioner tries to jumpstart labor with a variety of different methods. Sometimes, your or your baby’s health can indicate that a scheduled Cesarean birth would be the safest course of action.

Bringing Someone to Prenatal Care Visits

You are always welcome to bring someone with you to your prenatal care appointments. In fact, it is very special to share some of the visits with your partner or other family members and friends. It can be particularly helpful if you are getting certain tests or have hard questions to ask (and need some help remembering them, as well as the answers you get).

Homebirth Prenatal Care

Prenatal care for homebirth will look largely the same in terms of timing. Some midwives and doctors who do homebirths will provide all prenatal care services at your home. Some will have an office where you will attend prenatal care visits. If your midwife has an office, you will still probably have a home visit at some point later in your pregnancy.

Asking Questions in Prenatal Care

The questions that mothers have during prenatal care vary trimester to trimester. First trimester questions are often about the viability of the pregnancy, medical history, fetal development, etc. The second trimester is usually more about life in pregnancy. Can I eat this? Should I avoid that? What about my pets? Third trimester questions tend to be more about the actual birth and potential postpartum issues.

Remember, your prenatal visit is the time for you to ask very specific and targeted questions. To make the most of that time, consider keeping a running log of your questions in between appointments so that you don’t forget them.

If you feel like you don’t have enough time for questions, be sure to speak up. Talk to your provider about how to get your questions answered in the most productive manner. For example, should you schedule your appointments at the end of the day? Sometimes you may need to schedule a special appointment for a lengthier issue. It’s also important to remember that if you want to ask questions, but feel uncomfortable in the exam room, you can ask to move to the practitioner’s office space. That is one of the reasons that they have this space available.

Alternative Models of Prenatal Care

There are some varieties of prenatal care. One is called centering pregnancy. In it, you meet with other pregnant people and discuss life in pregnancy and ask questions in a group setting. You will test your own urine and mark your own weight in the chart. You will also have private time to talk to the midwife or doctor and conduct other portions of your care.

Paying for Prenatal Care

Prenatal care appointments may be charged for as a group or per individual appointment. If you have insurance, you may not have a co-pay, as this is considered well care. The charges for people who do not have insurance will vary.

The birth is billed for separately, typically because the person who does your prenatal care may not be the person who assists you at your delivery. This is true even if that person is in your prenatal care practitioner's practice. You will also wind up paying a hospital or birth center fee. All of these fees are subject to differences based on where you are located.

Sources:

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