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

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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.

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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

Childbirth Choices Series Part II: Meeting Your Care Provider

This is the second 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 III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

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So, let's talk about that first meeting with a potential care provider. What are you looking for in a care provider? How do you know if this person is the one you'll want to see throughout your pregnancy? How do you know this is the person you want to help you deliver your baby?

Your first meeting can be a simple "meet and greet" appointment even before you're pregnant, just to get a feel for the practice, his or her personality, how the office is run, and other general impressions, as well as a chance to ask specific questions relative to your situation. Your first meeting might be early in your pregnancy, when you're still looking for someone to help you through the rest of this process. Or, you might have a care provider you've been seeing for your GYN care, and this is your first prenatal appointment. Keep in mind that often the first prenatal appointment isn't until you're 8 or 9 weeks along, so there will be some time for you to think about your concerns and questions you might want to ask. Your pregnancy will  be pretty well established by the time you have your first regular prenatal appointment.

Depending on whether this is a meet-and-greet or a prenatal appointment, the atmosphere of the meeting may be different. I'll start with the universals, things you'll probably want to ask or judge your impressions of no matter what. I'll then move on to a typical "first appointment" scenario.

What kind of provider are you looking for?

We discussed in the previous article the three basic options for a maternity care provider (CP). These were a certified nurse-midwife (CNM), a licensed midwife (LM/CPM), or the most common choice, an obstetrician (OB). Now I want to look at the type of person or personality you might be looking for. 

We all have different expectations when it comes to someone who will be providing us with medical care. Some may prefer a certain clinical distance: you don't want your CP to be your friend, you want your CP to be professional, reserved, authoritative, and objective. Others prefer a warmer or friendlier relationship: you want someone you connect with on a personal level, someone you'd like to go out for coffee with. Still others might like a mix of the two: someone you feel meshes with your personality, sense of humor, and style, but who still maintains a comfortable distance. Remember that this person will become fairly intimately involved with your most private and sensitive of areas, so you want to make sure that you are personally comfortable with him or her, however that comfort is manifested for you. You should think about what kind of personality you're looking for as you prepare for your first meeting so that you can assess whether this person meets that need. Since you'll be seeing this person fairly regularly for the next several months, you don't want to dread your appointments because you don't "like" him or her!

Male or female?

While most midwives are women (probably over 99%), there are about the same number of male obstetricians as female. Female doctors are increasingly joining the field of obstetrics, and many patients prefer a female obstetrician, for various reasons.

I have been equally happy (and in some cases equally dissatisfied) with male and female CP's over my four pregnancies. Several of the most celebrated obstetricians in the natural birth community in my local area are male. I don't think you can make any kind of sweeping generalizations about male or female practitioners being "better." It's really about your personal preference.

Why a woman?

Some women are simply more comfortable being unclothed in front of another woman. This is quite understandable. You may also feel that a woman will have more empathy for your situation, especially one who has given birth herself. You may feel a certain sisterhood with her, or feel that her personal experience is to her benefit as a practitioner. You may feel more comfortable discussing intimate problems with a woman, because you feel she may have "been there" herself, or that she will understand why it's difficult for you to talk about. There's a peer relationship you can have with a woman that you can't necessarily have with a man.

Why a man?

Some women feel that a male practitioner will have a more objective view of the process. Having not experienced childbirth or other "woman problems" directly may mean that he will view your situation with a clinical eye not clouded by feelings. You may feel he is better able to distance himself from the emotions of the situation in order to give you the best objective advice. Indeed, does a cardiologist have to have had heart surgery to perform it? Does a pediatrician need to have children to take good care of yours?

What if I don't have a preference?

Some women don't have a gender preference for their CP. Sometimes, you're just looking for the best fit, the person who is best at the job at hand and who meshes best with your expectations. You may feel going in that you couldn't possibly be examined by a man but then find that the woman you choose is not as empathetic as you hoped. Or, you may think that you prefer the objectivity a man will likely provide, only to find that his approach is too clinical and you prefer a warmer touch. There's no way to generalize. Midwives and doctors are human, too, and their practice is colored by their training, their background, their personal experiences, and their personal biases. That's why it's prudent to have an open mind when interviewing or meeting with your practitioner.

Group Practice or Individual?

We talked about the different advantages of a group practice versus an individual practice in the previous article as well. 

If you're going with a group practice, it's a good idea to try to make appointments with each of the available providers throughout your pregnancy so that you'll get a chance to meet everybody. In a group practice, you would hope that there's a unifying philosophy among the members of the practice. However, each doctor or midwife in the practice may have a different style and will certainly have a different personality, and you may find you simply "like" some of them better than others. It's up to you to decide whether you can be comfortable with whoever ends up attending your delivery. I was with a group practice in my first pregnancy, and I definitely found I preferred two of the doctors over the other two. Toward the end, we scheduled all of the appointments with our "favorite" doctor, but he didn't end up being on call for the delivery. But, we were comfortable enough with the level of knowledge and competence, as well as the personalities, of each of the four doctors that we were willing to "take what we got" when it came time to have the baby. 

With an individual practicing on his or her own, a major concern will be whether this is the person who will attend your birth. Some individual practitioners cannot guarantee that they will be available or on call when you go into labor, while others make it a point to be there. This is something you'll definitely want to find out early on! If your doctor or midwife can't be there for the delivery, then whoever is on call at the hospital or birth center will be there for your birth.

What do I want to know?

Okay, so what questions should you be asking, and what information should you be sure to acquire? Well, there are a few things you'll definitely need to know. 

• Where will I deliver my baby? What hospital or birthing center does this CP deliver at? (For a home birth, this is obviously not a relevant question.) 
• Who will deliver my baby? This goes back to the on-call situation: are you the one who will be there when I call to say I'm in labor, or is there no guarantee? If you are not available, who can I expect to see? Do you have arrangements with another practice to work with you for backup, or am I stuck with whoever is on call? How much of an effort do you make to be there personally?
• What is your cesarean section rate? This question applies to OB's, since midwives can't perform c-sections. Midwives in birth centers and the home-birth setting will instead have a "transfer rate" - that is, how often the patients in their care need to transfer to the hospital for emergency care. This is something you will want to find out if possible. Knowing if your OB has a relatively high c-section rate (the national average is about 32%, which most experts agree is too high) or a relatively low one may help you decide if you feel you are in capable hands. An OB with a lower rate is probably more "hands off" in the birth process, more inclined to let things happen naturally. An OB with a higher rate may be more likely to err on the side of caution if there are any concerns during the labor process. Remember that OB's who handle more high-risk cases will likely have higher c-section rates by virtue of their type of practice and not necessarily because of their philosophies.
• What kinds of recommendations do you make for managing the pain of labor? This is going to be a big question. What you're trying to find out is, how likely is this person to immediately turn to medical interventions such as epidurals and IV narcotics before or instead of trying non-medicinal methods of labor relief, such as breathing, changing positions, shower or bath, and relaxation techniques. Is this a CP who is more likely to let labor progress on its own, or is he or she going to recommend interventions early on? How do you as the patient feel about that? Are you more interested in "letting nature take its course," or do you feel strongly that you want an epidural the second you walk into the hospital? Are you more comfortable with laboring in more hands-off environment, or are you nervous about laboring without monitoring and assistance? These are very, very important questions for you to consider as you progress through your pregnancy, and we will definitely be addressing the issues of interventions, medications, and monitoring in a future article in this series. How your CP answers this question will help you understand how he or she views the birth process and how you as the mother will be treated.
• What is your (or the hospital's) policy on continuous fetal monitoring? Continuous fetal monitoring (CFM) means that you would wear a fetal heart monitor strapped to your belly at all times. This is a tool that we will discuss in more detail in a future article. You may want to know if you will be required to wear this monitor at all times, as it may limit your mobility and ability to change positions or use alternative pain relief options such as a shower/bath, and CFM has some unexpected risks, such as increasing your chance of emergency c-section. You may want to follow up on this question by asking if intermittent monitoring is an option. In this scenario, you'd wear the monitor for 20 minutes every hour and otherwise be disconnected and free to move about, if you want.
• What is your policy on eating and drinking during labor? What is your (or the hospital's) policy on the use of an IV? Labor can be long and uses a lot of your energy. Many CPs and/or hospitals will not permit a laboring woman to eat or drink during labor in case she requires an emergency c-section and emergency anesthesia. You will want to know if you'll be allowed to bring food and drink with you to fuel your labor. Often, if your provider or birth location has a policy against eating and drinking during labor, they will require you to be on an IV for fluids at all times to prevent dehydration in you and the baby. They may also prefer to have an IV ready in case any medications such as antibiotics or Pitocin are deemed necessary.
• How do you feel about my having a doula? Even if you don't plan to hire a doula (and we'll talk about doulas in a later article, too, never fear!), you may want to know whether your CP is open to your having a labor coach or additional support in the room with you. A "doula" may also simply be a friend or family member who is there to encourage and support you as you labor. Most CPs, birth centers, and hospitals are amenable to the presence of a labor support person other than the baby's father or a close family member, but some are not. Knowing your CP's attitude on this subject may be informative for you.

These questions should help you gauge your potential provider's approach to labor and birth so that you can determine if these ideals are in line with your own. We will be getting into considerably more detail about many of these topics in future articles, to help you gauge your own birth preferences, as well!

Your First Prenatal Appointment

This is a description of what typically goes on during a first prenatal appointment, especially in a more traditional setting, just to give you an idea of what to expect.

You'll first be asked to fill out some paperwork about your general health history and gynecological history specifically, especially previous pregnancies and births, if applicable. Your provider may have these forms mailed to you in advance of your appointment so you can arrive with them already completed, or you may be asked to fill them out when you arrive. You'll probably need addresses and phone numbers to use for emergency contacts, how to contact you and your partner at work, your insurance information, and so on. You may also want to have on hand information about previous GYN care providers and be prepared to have your records transferred if you are moving to a new provider. It's important that your provider has a picture of your medical history so that they can care for you appropriately. Conditions such as diabetes, hypertension, thyroid issues, psychological disorders, and various GYN problems will likely be relevant to your treatment during pregnancy and delivery and possibly postpartum as well.

You'll probably be asked to provide a urine sample (by peeing in a cup), which will be quickly tested for protein and glucose content. The presence of protein in your urine could signal kidney problems, which would need to be evaluated. Glucose in the urine may indicate diabetes or the potential for diabetes, which would need to be managed.

You'll then be taken to the exam room. Your provider will most likely want to perform a full gynecological exam. For this, you'll be asked to take off all of your clothes, and you'll probably be given either a hospital gown or a paper vest and towel to put around yourself. (From personal experience, I recommend keeping your socks on if you're wearing socks - sometimes the room is cold, or the stirrups are uncomfortable on bare feet.) The care provider will examine your breasts and genitals and do a quick internal vaginal examination with gloved fingers and possibly a speculum to check your cervix and feel for your uterus and ovaries. If you have had a gynecological exam before, this should all be familiar to you.

Many care providers will then perform a transvaginal ultrasound to "see" the pregnancy. An ultrasound machine measures the way high frequency sound waves bounce off various structures in your body and creates a live picture on a computer screen of the tissues, organs, and bones the sound waves encounter. The provider can manipulate this picture to focus on the organs of interest, in this case your ovaries and uterus, and to view the growing fetus. You may be familiar with a traditional ultrasound machine, which uses a wand and some gel on your abdomen. For this type of ultrasound machine to get a clear picture, you generally need to have a full bladder. A transvaginal ultrasound, by contrast, uses a wand that is covered by a lubricated condom and inserted into your vagina. It does not require a full bladder to get a clear picture of your uterus, cervix, ovaries, and the baby. The provider will use the ultrasound machine to take measurements of the fetus and look at the heartbeat as well as to check the placement of the pregnancy to make sure everything looks healthy. Based on the measurements on the ultrasound, your CP can get a pretty good idea of how many weeks and days the baby has been growing, and from there determine whether your estimated due date, based on your last menstrual period, is accurate or if an adjustment needs to be made. If the estimate from your ultrasound and your last menstrual period are within a few days of each other, your due date will probably not be changed. If there is a larger difference, they may want to change the date based on the baby's actual growth.

If you are not comfortable with the idea of an ultrasound in general, or a transvaginal ultrasound specifically, you should bring up your concerns with your provider. It is your right as the patient to refuse any procedures you feel are unnecessary or carry unreasonable risk to yourself or your baby. Though it is a useful tool, an ultrasound is not necessary to date or assess the pregnancy. You should feel comfortable asking your provider what the purpose of the procedure is and whether and why he or she feels it is important. While you may not be able to hear the baby's heartbeat using external methods (such as a Doppler machine or stethoscope) at eight or nine weeks, by about 12 weeks it is possible to hear the heartbeat using noninvasive methods, and you may be more comfortable simply waiting to use a less intrusive method to hear the heartbeat. On the other hand, you may be excited to get to see your baby so soon (no, you can't see the gender this early!), and seeing the little heart fluttering on the screen is very reassuring.

You will also be given information about certain blood tests your CP recommends. These will include general blood tests such as checking your blood type, measuring your iron stores, thyroid function, and white blood cell count. Your CP will also likely recommend that you be tested for antibodies to certain diseases such as chicken pox, measles, rubella, and other viruses that may be dangerous to a growing fetus. If you have had any of these diseases in the past, or you have been vaccinated against them, there should be nothing for you to worry about. There is a blood test, as well, to look for certain chromosomal abnormalities in the fetus, specifically Down syndrome. Your CP will ask if you would like to receive this testing and give you information about how it works and what they look for.

Your CP will also discuss with you whether you want genetic testing to find out if you are a carrier of any known genetic diseases such as cystic fibrosis, sickle cell anemia, or Tay Sachs (depending on your ethnicity and risk of being a carrier). If you are a carrier of a genetic disease and the father of the baby is as well, there is typically a one in four chance that your baby will have that disease. You may want to know whether your baby is at risk of having one of these terrible genetic disorders. Some people choose to be tested for this before deciding to have a baby, but often you don't know about them until you are pregnant. If anything is found, you can receive genetic counseling to help you decide what to do and how to handle future pregnancies.

Remember, again, that you have the right as the patient to refuse any tests or procedures you are not comfortable with. For example, if you don't think that knowing the results of a genetic test would change your desire to carry your pregnancy to term, then you may want to decline the testing. On the other hand, knowing about a potential disability or disease may be important to you, even if you still plan to carry the pregnancy to term, so that you can be prepared with services and support when the baby is born. You probably want to discuss this decision with your partner to make sure you both feel the same way.

Your next appointment will likely be scheduled for four to six weeks in the future, and you will probably be asked to have your blood tests in the meantime. Some blood tests need to be taken during a specific time frame for accuracy.

Your provider will then likely discuss with you some issues such as exercise and diet and what you can expect in the next few weeks. You should be given an opportunity to ask any questions you may have and air any concerns that have come up.

If, for any reason, during your appointment, you feel uncomfortable, you should let the provider's office know via a phone call or, better, a letter. If it's in writing, you have evidence of what you said. If you do not wish to return to see this provider, start looking for a new one quickly so you can schedule your next appointment, and arrange to have your records sent over to them. You also have the right to request a copy of your records to keep for yourself if you want. The provider's office may charge a copying or processing fee, usually not more than $25, for the time and supplies used by the office staff in copying the records, but they are not allowed to refuse to give them to you.

If this is not your first pregnancy and there was anything of note or unusual about your previous pregnancy(ies) and/or delivery(ies), you may also want to request your hospital records from the birth(s) so that your new provider will know about these circumstances. That information can be valuable in planning your next birth.

Stay tuned for the next article in this series. If you have any questions about this or any of the topics covered in the Childbirth Choices Series, feel free to comment below or on my Facebook page, or send me a private message via the Facebook page.

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More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's almost Time to Have a Baby!
Part VI: Labor and Delivery