Thursday, September 19, 2013

Childbirth Choices Series Part IV: What Will Happen at My Prenatal Appointments?

This is the fourth in my Childbirth Choices Series, geared toward newly pregnant or planning-to-be pregnant couples with the goal of educating women and their partners about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

More articles in this series:

Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part V: It's almost Time to Have a Baby!
Part VI: Labor and Delivery

Now that you've chosen a care provider and a birth venue and started to learn more about the birth process, you'll settle into a routine of regular prenatal visits. In this article, we'll discuss what a typical prenatal appointment will look like, and the schedule of appointments you can expect as your pregnancy progresses. We'll also talk about some of the tests and procedures your provider may suggest or prescribe.

During your first and second trimesters, your provider will probably want to see you approximately every four weeks. Once you reach the third trimester, from about 30 weeks until 36 weeks, you'll be seen every two weeks, and then every week until you deliver. Often, they'll suggest that you schedule these appointments well in advance, as the coveted time slots fill up fast. (Please note that some of this will only apply in a clinical or office setting. Home birth midwives may follow a slightly different procedure, although the exam and visit will cover the same bases.)

A Routine Prenatal Appointment

A typical routine prenatal appointment (except the first one, which we talked about in Part II) will look something like this:

You'll be asked to provide a urine sample*, which will be tested for glucose and protein using a special paper strip dipped in the cup of urine, which will then be disposed of. If the results are negative, you don't have to worry about anything. If there are any concerns, the nurse or assistant will notify the provider so that they can follow up.

*Some tips for peeing in a cup, for the uninitiated. I should say that by the end of your pregnancy, you'll be a peeing-in-a-cup pro. I usually try to drink a glass of water just before I leave for my appointment. This way, I'll be sure to need to pee when I arrive. Especially in the later months, peeing on demand is typically not a problem. Take the cup they provide and keep it near the toilet. Sit down on the toilet and hold the cup under your vulva, but not touching, and allow your stream to start. You may find you need to hold the cup a little farther back than you might expect. And, yes, you may find that you do pee on your hand once or twice until you get the hang of it. Fill the cup about halfway - you don't have to impress them with volume; they just need enough for the quick dip test - and finish up in the toilet. I like to wipe the outside of the cup with some toilet paper in case I dripped on the outside at all. Put it down wherever you can and finish up your bathrooming as usual. They'll tell you what to do with the cup afterwards. 

You'll then be weighed. Your provider will want to monitor your weight gain to make sure you're not gaining too little or too much. There's a wide range of "normal" when it comes to pregnancy weight gain, but if you're not gaining weight at all, this may indicate a problem and could be dangerous for the baby. Conversely, if you're gaining weight very rapidly, this could signal a different set of problems that may need to be investigated, such as gestational diabetes or a thyroid issue that can be managed.

Your blood pressure will be taken. It's important to monitor blood pressure, as a rapid rise in blood pressure, or sustained high blood pressure, can indicate a serious, even life-threatening, disease called preeclampsia. The only "cure" for preeclampsia is delivery of the baby, although often the high blood pressure can be managed if it is too early in the pregnancy to safely deliver the baby. Preeclampsia can cause serious problems, including stroke, in the mother and low birth weight for the baby, so it's important to keep an eye out for. The cause of preeclampsia is unknown.

You'll then be seen by your provider. He or she will use either a stethoscope or a special monitor called a Doppler to listen to the baby's heart beat and record the heart rate. A fetal heart rate ranging from the 120s through the 140s is normal. The provider will then measure your "fundal height," which is the distance from the top of your pubic bone to the top of your uterus (the fundus). Typically, the fundal height in centimeters should approximately match the number of weeks of your pregnancy. This is a noninvasive way to make sure the baby is growing normally. Assuming there are no concerns with your urine, weight, or blood pressure, which, for the majority of women, there likely will not be, that's all you'll need to do at most of your appointments.

The exam part of the visit is usually quite short, and then your provider should give you an opportunity to bring up any concerns or ask any questions you may have. I find that often by the time I'm actually in the exam room, I've forgotten all the questions I've thought of over the past few weeks between appointments. It may be a good idea to write down some of your concerns so you can raise them at the appointment. You may have concerns about discomfort you are experiencing, pain you're not sure is normal, unexpected symptoms, or questions about your lifestyle or diet. Don't be embarrassed or timid about raising any concerns you may have. Usually, your provider will be able to reassure you that what you're experiencing is normal and may have suggestions for relieving or reducing discomfort or pain. It may also be that one of your symptoms is the result of a disease or disorder that can be treated, from a yeast infection to a urinary tract infection (both quite common in pregnancy), to something more serious. Don't write off anything as "just because you're pregnant." If you feel your provider doesn't take your concerns seriously, you may want to seriously consider changing providers or seeking a second opinion.

At some appointments, your provider will likely order certain blood tests. Usually, these tests look at iron levels, thyroid function, platelet counts, and other useful information to help assess your health and the health of your pregnancy. 

Glucose Tolerance Test

Around 25 weeks, you'll be asked to have the glucose tolerance test, which determines how well your body is processing glucose. If this test comes back outside of normal range, you may need to be assessed for gestational diabetes.

The glucose tolerance test is reasonably simple. There are several versions of the test. The most common first test is the one-hour test. You'll be given a bottle of a cold, sweet drink that tastes roughly like flat orange Fanta. Some women find this quite unpalatable, while others don't mind it. This drink has a specific amount of glucose in it and is used only for this type of test. You must finish drinking the whole bottle within five minutes, and you'll be asked to note the exact time you finish drinking it. Exactly one hour after that, your blood will be drawn, and they will test your blood sugar levels. You cannot eat or drink anything during that hour, because anything you eat or drink (except water) will affect your glucose levels. Usually you'll simply wait at the lab, so bring a book or something!

Some providers will order instead a two-hour glucose tolerance test, which is essentially the same thing except will require you to wait two hours until having your blood drawn.

If this initial test is within normal limits, you're fine. If it's not, you may be asked to do a three-hour test. Most women "pass" this three-hour test and have no further concerns. If you do not, you'll probably be assessed for gestational diabetes (GD). Gestational diabetes can often be managed by diet alone and will resolve once the baby is born. Women diagnosed with GD may be at increased risk of developing Type II diabetes in the future, as well as at risk of unhealthy weight gain during pregnancy and other complications.

Do I need to do the GD screening?

Of course, as I've mentioned before, you don't need to do any of the tests or exams your provider recommends. However, the GD screen is relatively simple, mostly noninvasive and very low-risk, and merely takes a some of your time. Identifying GD is important, and ruling it out gives both you and your provider peace of mind. If you are stalling or hesitant due to the amount of time involved, you may be able to discuss other options with your provider for GD screening. There is a test which allows you to eat a very specific breakfast and simply have your blood drawn at a specified time after eating, as the glucose level of the foods will be known. There are also other ways of monitoring your blood sugars on your own to determine if your body is properly processing glucose, which you may find preferable to the standard tests described above. Discuss these alternatives with your provider if you're not sure about your ability to do the more standard tests.

Anatomical Ultrasound

Between 16 and 20 weeks, typically, your provider will order the complete anatomical ultrasound. For the ultrasound machine to get an accurate and clear picture of your uterus and it's precious contents, you'll need to have a full bladder. You'll receive instructions on how to achieve this. Generally, you need to drink about 32 ounces of water in the 60 to 90 minutes before the test. Your full bladder will help push the uterus up and out of the pelvis as well as providing fluid for the sound waves to travel through. Having such a full bladder may be uncomfortable. At my ultrasound in my third pregnancy, the technician actually had me go to the bathroom and pee out a limited amount (she gave me a 16-ounce cup to fill) because my bladder was too full. What a relief that was! However, if your bladder is not sufficiently full, the ultrasound may have to be rescheduled, as a clear and accurate picture is necessary.

This is the ultrasound at which you can usually determine the gender of the baby. But that is not the primary purpose of this test. The ultrasound technician will examine your baby from, literally, head to toe, measuring the bones of the skull, looking at the brain, the structures of the face and neck, the spinal cord, the heart, lungs, kidneys, and other internal organs, the arms and legs, hands and feet, fingers and toes. It's really quite fascinating. I enjoyed my ultrasound very much, especially because the tech was very friendly and open about showing me everything she was looking at. They'll also look at the placement of the placenta (to make sure it's not in danger of blocking the cervix), the structure of the umbilical cord, and the length of the cervix. It's very comprehensive. The tech should ask you if you want to know the baby's gender and will take a peek between the baby's legs if you say yes. Remember that the technician can't diagnose anything or identify problems. The technician merely takes the pictures. Interpreting the ultrasound is the job of the radiologist who reviews the ultrasound report. If the radiologist finds any problems or concerns, he or she will notify your provider, who will contact you to discuss the next steps.

Do I need the anatomical ultrasound?

Again, usually, you don't need any of the tests your provider will suggest. These tests help assess your health and the health of your baby and may identify conditions in mother or baby that can be managed or treated. In some cases, they may reveal irreversible genetic or congenital disorders in the baby, or structural problems in the uterus, placenta, or cervix that may affect the birth.

While routine ultrasounds have been performed for about 30 years now without any major risks being identified, they have also not been shown to necessarily improve outcomes, either. For this reason, some women feel that it is not necessary to have the 20-week anatomical ultrasound, as they do not wish subject their bodies or their babies to any unnecessary interventions or tests that do not have a proven benefit. You are always within your rights as a patient to refuse any tests your provider orders, for whatever reason, including financial. If you are paying for your prenatal care or birth out of pocket, for instance, the ultrasound may be an expense you choose not to undertake.

Other Tests

If your pregnancy is progressing normally and no problems are detected, those blood tests and the ultrasound will probably be all that your provider will order. However, if any of these routine tests turn up a possible problem, there are other tests you may be asked to undergo. These range from additional blood tests to additional ultrasounds to more invasive testing such as amniocentesis. If your provider recommends any of this additional testing, don't be afraid to ask questions, investigate risks to you and the baby, and decide for yourself what is necessary and what is alarmist. There's far too much to get into here, as this series is meant to cover the course of a normal pregnancy, but I wanted to mention that there may be more depending on your personal risk factors.

Cervical Checks

In the last few weeks of your pregnancy, your provider may want to check your cervix. Some providers and women like to know if there has been any dilation (opening of the cervix) or effacement (thinning of the cervix), which may indicate whether your body has started preparing for labor and delivery. Routine cervical checks prior to labor are controversial and generally not useful or necessary. Often, the cervix will show little-to-no dilation or effacement before labor begins, and even if you are dilating and beginning to efface, that does not mean you'll go into labor tomorrow. Some women walk around at 4cm of dilation for weeks before active labor begins, while others are at 1cm at their 40-week prenatal appointment and end up in labor that same day. In other words, you and your provider may want to know if anything's "happening," but whether anything's happening may not actually have any bearing on when you'll actually give birth. Checking the cervix will, of course, involve undressing from the waist down and allowing your provider to insert two fingers into your vagina to measure the cervix. Some women are sensitive to these types of exams and may experience discomfort or spotting after a cervical check. If you are uncomfortable with the idea, you may tell your provider that you prefer not to have any cervical checks.

GBS Testing

Between 35 and 37 weeks, your provider will likely want to perform a Group B Strep test. For this, you will need to undress from the waist down, and your provider will swab your vagina and anus. This sample will be tested for a specific type of bacteria called Group B Strep (GBS). The presence of GBS is not harmful to you, but it can cause infection in the baby at birth, requiring the use of antibiotics and possibly other interventions such as a brief NICU stay. Women who test positive for GBS will likely need to receive IV antibiotics during labor to reduce the risk of the bacteria infecting the baby as he passes through the birth canal. You can discuss the procedures for giving birth when GBS+ with your provider if you do end up testing positive.

Non-Stress Test

If you are experiencing any complications such as high blood pressure, or if you go beyond your estimated due date, your provider may order a non-stress test (NST). An NST will help determine if the baby is reacting normally to his own movements. An NST is noninvasive and requires only the use of fetal monitors, which are strapped to your belly and measure the baby's heartrate and the contractions of your uterus. You will relax for 20 to 40 minutes, preferably after eating and emptying your bladder. The baby's heartrate will be recorded. The expectation is that the baby's heartrate will increase when he moves. The nurse conducting the test will watch for at least two instances of the baby's movements and confirm that the baby's heartrate increased by a certain amount during those movements. If the baby is reluctant to move, you may be asked to drink a glass of orange juice or very cold water. This will usually encourage the baby to kick. They may also use a buzzer to startle the baby to get him to move. 

While you are there, they may also conduct an ultrasound to determine your levels of amniotic fluid and to view the placenta. 

Assuming the baby reacts as expected and there are no other concerns, you can feel comfortable continuing on as you are and wait for labor to being naturally.

Weight or Size Estimate Ultrasound

Some providers may want to use an ultrasound toward the end of the pregnancy to estimate the size or weight of the baby. While it may be fun for you to "see" the baby again, please note that ultrasounds are a notoriously unreliable way to estimate the size of a baby in utero. Be aware that the ultrasound estimate may be off by as much as one and a half to two pounds in either direction. In other words, if your provider estimates that your baby will be 8 pounds, that means your baby could be anywhere from a petite 6 pounds to a robust 10! Or, just because the estimate says 10 pounds doesn't mean your baby will actually be unusually large. He may come out a healthy 8 or 8.5 pounds. Also be aware that the size of the baby generally does not have much effect on whether you will be able to give birth vaginally, if that is your desire. Listen to your provider's suggestions, but be armed with your own research on the subject as well, and  be ready ask questions if your provider recommends inducing before 40 weeks because of "macrosomic" (large-bodied) baby. We'll discuss induction, c-section, and interventions in a later article.

Membrane Stripping and Breaking of Waters

At 39 or 40 weeks, or if you go beyond 40 weeks, your provider may offer to "strip your membranes." It is thought that doing so may jump-start labor in a woman who is on the brink. Stripping the membranes involves the provider inserting his or her finger into the vagina and sweeping the cervix, separating the membrane that connects the amniotic sac to the wall of the uterus. This is typically an uncomfortable procedure, though relatively quick, and may cause cramping and contractions in the hours following. If successful, you will find yourself in labor not long after your appointment. However, it may not work if your body or your baby are not quite ready to go into labor, and you may experience a fair amount of discomfort to no effect. When it was looking like I was getting close to going into labor toward the end of my third pregnancy, my midwife stripped my membranes. For about an hour (in Toys R Us with my kids, no less), I was certain I was about to go into labor. I felt horrible. And then it all stopped and I went into labor spontaneously two weeks later.

A more extreme way to attempt to induce labor without drugs is to manually break the amniotic sac. If your cervix is dilated at all, your provider can use a tool to poke a hole in the sac, releasing the waters. This may trigger labor. However, once the amniotic sac is broken, your uterus and baby are vulnerable to infection, and if labor doesn't begin on its own within about 24 to 48 hours, your provider will recommend you go to the hospital immediately to be induced with Pitocin or to have a c-section. Please note that once your water is broken, whether spontaneously or manually, you should not put anything into your vagina, to reduce the risk of introducing infectious agents into the uterus.

I mention these various procedures so that you'll know what your provider is talking about when the time comes. This gives you the opportunity to do your own research on the various topics as they become relevant so that you can ask educated questions and make an informed decision when presented with the option. 

Please remember that the average first pregnancy goes beyond the 40-week estimated due date, and even on to 41 weeks. If your pregnancy is otherwise healthy and there are no concerns, you do not have to feel pressured to attempt to induce labor by any means (natural, manual, or using medication). Have an honest discussion with your care provider about the risks and benefits of allowing your body to progress to spontaneous labor.

More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part V: It's almost Time to Have a Baby!
Part VI: Labor and Delivery

No comments:

Post a Comment