The Pregnancy Initial Visit
Posted on October 14, 2007
Filed Under Pregnancy Care | Leave a Comment
As soon as you think or know you are pregnant, you should contact a specific pregnancy care provider-see the preceding pages. The initial pregnancy visit should occur sometime in the first 12 weeks-or first trimester-of pregnancy. Optimally, it should take place when you are about 6 to 8 weeks pregnant. If you haven’t had a preconception visit, the first pregnancy visit will be lengthy, and include all the components of the prepregnancy visits . If you had a preconception visit, the first pregnancy visit will be fairly short; it will involve updating your health history, reviewing the laboratory tests already completed, perhaps repeating a few of these, and redoing parts of the physical examination. It will include an abdominal exam and a pelvic assessment, depending on how pregnant you are.The update of your health history will cover any early pregnancy danger signs that you may have had, such as bleeding and cramping, as well as normal but troublesome symptoms, such as nausea, vomiting, and headache. Your physician or midwife will ask if you have had any X rays since becoming pregnant, if you have been sick or exposed to any diseases, and if you are taking any medications.
The abdominal and pelvic examinations are to measure your uterus and compare its size to the size expected for how pregnant you are, based on your last menstrual period. If you are less than 12 weeks pregnant, your uterus is still too small to be felt in the abdomen, so it can only be measured by feeling it through the vagina. A nurse, midwife, or doctor will check your weight and blood pressure, as they will on all prenatal visits. Your urine also will be checked.
Some practitioners routinely perform clinical pelvimetry on a first prenatal care visit. This means they feel, with their fingers, the size and shape of the pelvic cavity by palpating, through the vagina, the circle of bones that create the pelvis. This makes the vaginal examination slightly longer and a bit more uncomfortable. It alerts the practitioner to any structural abnormalities and gives a rough estimate of the likelihood that a normalsized baby will fit through. Many practitioners, however, have given up this practice in prenatal care, believing that pelvic bones loosen and expand in labor and that the strength and frequency of contractions as well as the position of the baby are more important indicators of whether the baby will pass through the pelvic cavity. Pelvic abnormalities were more common in the days-long gone in this country-when women suffered in childhood from rickets, a vitamin D deficiency. Yet many physicians and midwives still feel that knowing that a woman has an adequate pelvic size can be reassuring if labor proceeds slowly, and simply do not wish to lose this old-fashioned skill. A history of a fractured pelvis or structural abnormality is certainly a reason for your physician or midwife to perform clinical pelvimetry. Otherwise, this assessment is optional.
Whether or not you have had a preconception visit, one of the goals of the first pregnancy visit is to determine your due date-once known as the expected date of confinement and now called the expected date of childbirth (EDC) or expected date of delivery (EDD). At the end of your first prenatal visit, you will usually know how pregnant you are and approximately when you can expect to deliver. Remember, of course, that this date is only an estimate. It is really the midpoint of 4 week period. The baby can be born any time two weeks before or two weeks after this date.
Of course, the first prenatal visit is a time for you to ask all the many questions that have come to mind since you discovered that you are pregnant. These may include questions about prenatal care, fetal growth and development, exercise, sex, work, childbirth education, discomforts you might be experiencing or expect to experience, medications, infant feeding, maternity clothing-just about anything. Many of these should have been answered in advance if you had a preconception visit.
Other family members, including your husband or partner, your children, and your parents, may have questions. They can ask these if they come with you to the visit or you can ask for them if they are unable to attend or if you prefer coming by yourself or with only one family member.
Whether or not you ask questions, your physician or midwife may raise certain issues with you. These include physiologic and emotional changes of pregnancy, nutrition, vitamin and iron supplementation, the important option of in-depth HIV counseling and testing, safer sex, avoidance of toxic substances and drugs, giving up smoking and drinking, activity and exercise, and early pregnancy danger signs.
Routine Testing in Prenatal Care
The following table of laboratory tests utilized routinely in pregnancy, or within a year prior to pregnancy, was adapted from the recommendations of the Expert Panel on the Content of Prenatal Care. Some tests are advised for all women, others only for women at risk for particular problems. Most of these are performed to look for conditions that share a number of characteristics: these conditions are found somewhat commonly in young women yet most often have no obvious symptoms and they may affect pregnancy, the developing fetus, or the newborn. Some physicians or midwives may choose to alter the specific tests used or the timing of such tests. Some women may need additional tests.
You may notice that ultrasound, which has become widely used in pregnancy care, does not appear in the table of routine tests. Although generally considered a safe procedure whose benefits usually outweigh any possible adverse effects, its safety cannot be totally assured. For this reason, neither the National Institutes of Health nor the American College of Obstetricians and Gynecologists recommends routine ultrasound in pregnancy. Its use is reserved for selected reasons, of which there are many.
Subsequent Prenatal Visits
At all prenatal visits, your physician or midwife will review how you are feeling and whether you have experienced any danger signs. A nurse or your doctor or midwife will weigh you and take your blood pressure. Blood pressure measurements are especially important in the second half of pregnancy (after week 20). The growth of your uterus will be assessed abdominally; most physicians or midwives measure the height of the fundus (the top of the uterus) at each visit. They may measure with their fingers, using fingerbreadths above or below certain body landmarks, such as your navel, to ascertain whether or not your uterus is growing appropriately. They may measure with a tape measure in centimeters; there are 2.2 centimeters in 1 inch. From 20 weeks of pregnancy, when the fundus just about reaches the navel, to 36 weeks, the uterine measurement should approximately equal your weeks of pregnancy, plus or minus two centimeters. So, if you are 28 weeks pregnant, your uterus should measure 28 centimeters, or between 26 and 30 centimeters.
At about 20 weeks of pregnancy, the fetal heart can be heard with a special stethoscope called a fetoscope and will be listened to at each visit. If the tubing on the fetoscope is long enough, you might be able to hear your baby’s heartbeat, especially as the baby grows larger. Your partner can listen also, so can your other children or anybody who accompanies you to a prenatal visit. Many practitioners today use a Doptone or Doppler to hear the fetal heart; this instrument uses ultrasound (or sound waves) to amplify the fetal heart tones so that you can hear them loudly and earlier in pregnancy. The intensity of ultrasound used with this type of Doppler is so far below the level considered dangerous in humans, and the duration of exposure at each visit so short, experts have not questioned the safety of this application of ultrasound. The fetal heart can be heard quite early with a Doppler-sometimes at 10 weeks of pregnancy or even before. The value of this remains uncertain as not hearing it doesn’t mean there is a problem; it may just make you and your provider nervous.
Vaginal examinations generally aren’t necessary during the normal course of pregnancy, except to take a specimen for screening or when infection is suspected, or if you show signs of premature or preterm labor. Although some women like to know whether their cervix is thinning out or opening as their due date approaches, this doesn’t provide much useful information. The state of the cervix in late pregnancy is not a reliable predictor of either the onset of labor or its duration, but if pregnancy has exceeded the due date by at least 1 or 2 weeks, a cervical check may help decide the advisability of induction.
Several additional activities are important in prenatal care. Time should always be made available for you and your partner to ask questions. No topic should be considered silly or taboo. Danger signs appropriate to the timing of pregnancy should be reviewed at each visit. Plans for infant feeding and the conduct of labor should be discussed by the third trimester (approximately 24-26 weeks). Information should be provided to you about the signs of labor, including preterm labor; what to do when labor begins; and choices available for pain relief in labor, with discussion of their advantages and disadvantages. Information about childbirth education classes should be given fairly early in pregnancy. While most classes begin at the eighth month or thirty-second week, some types of childbirth education start earlier in pregnancy and these options should be made available.
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