Your 40-week Journey : Who will Handle My Care? A guide to prenatal care (part 1)

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What types of prenatal care are available to me?

Several different models of care are available and they are related to the type of care provider you choose. Certified nurse-midwives (CNMS) or certified midwives (CMS) are appropriate for the majority of women who anticipate a normal pregnancy and birth. Midwives work as facilitators and advocates and with other health-care providers. A family practice physician is another option. Family doctors take care of the health of their patients through all the stages of life. Check to make sure that your physician includes obstetrics in his or her practice. Unless there are complications, these physicians will deliver your baby. Obstetricians have education in surgery and management of complications of pregnancy. They may serve as consultants for midwives and family practice doctors and are a logical choice if you have a complex medical history or if there is a problem with the current pregnancy. A perinatologist is an obstetrician with advanced certification in high risk pregnancy management.

Q:	How many prenatal appointments will I need?
A:	The exact number of appointments and how often you have them depends on your individual situation. If you start your care early in the first trimester, you may have as many as 14 visits. Until 28–30 weeks, appointments are typically made monthly. After 30 weeks, plan to come in every two weeks. In the last month, visits are weekly until birth.

Q:	When will I have my first prenatal appointment?
A:	Your first prenatal appointment is usually between 6 and 12 weeks, depending on the doctor or midwife you choose.

I'm going for my first prenatal appointment next week—what will happen there?

The purpose of your first appointment with your health-care provider is to obtain your medical history and exchange information so that your future care during the pregnancy and birth can be planned. This is also a chance for you and your midwife or doctor to get to know each other and for you to ask any questions you may have and discuss the schedule for your appointments, blood tests, ultrasound scans, and prenatal classes. You will also be given written information, and important contact telephone numbers.

Your health-care provider will ask you about your last menstrual period, your medical history, your family's medical history, your partner and your partner's family's medical history, about any previous pregnancies you have had, and how this pregnancy has been so far. Your answers to these questions will help your midwife or doctor build a picture of your current state of health, and will also help identify any factors that may affect your pregnancy, for example, if there is a family history of preterm labor.

Your blood pressure and your weight will be checked and a urine sample will be requested. A pap smear and tests for sexually transmitted infections may also be performed. Your uterine size will also be assessed by means of an internal exam to see if your size matches your dates. If you are 10 weeks or more from your last menstrual period (LMP), the fetal heart tones may be audible with the Doppler. At the end of the visit, blood is usually collected for various tests. These observations provide a useful baseline for future prenatal checks.

Why do I have to leave a urine sample with the doctor?

Health-care providers may request a urine sample at the initial visit to test for infection. Another specimen should be collected at 28 weeks, and again at about 36 weeks and then every week until birth. Urine samples are requested to check for protein, glucose, and ketones. If protein is present, this could indicate that you have a urinary infection that may need a course of antibiotics. After around 24 weeks of pregnancy, protein in the urine is an indication of preeclampsia, a potentially serious condition that needs close monitoring.

Glucose in the urine is a sign of gestational diabetes. If glucose is present, you may be referred for blood tests to analyze your sugar levels.

I have a choice, should I see a doctor or a midwife?

It is a good idea to see a midwife at your initial visit and then a doctor at your next visit. You can ask questions and see which type of practice best suits your philosophy. At the initial appointment, the midwife can review your history and let you know if she or he thinks you may be a better candidate for physician care. Midwives believe in nonintervention in normal processes, preferring to use technology appropriately, when assessing for or managing potential problems. Midwives work with other members of the health-care team to provide optimal care. You can locate a midwife through the American College of Nurse-Midwives or through a local hospital or childbirth education group.

Will I have to have an internal examination at my first prenatal appointment?

It is likely you will have an internal examination at your first prenatal appointment as such an exam can help to confirm and “date” a pregnancy. The midwife or doctor places two fingers into the vagina, and presses on the lower abdomen with the other hand to judge the size of the uterus to assess the ovaries.

Part of the internal exam involves an internal examination with a speculum to allow the cervix to be seen. A small amount of bleeding may occur after an internal exam during pregnancy. This may be due to touching the cervix with the blades of the speculum and it is nothing to worry about.

The pap smear and tests for sexually transmitted diseases are all done with the help of the speculum. A vaginal swab can be used to assess for vaginal infection as well. Although internal examinations are not enjoyable, it is important to try and relax to help the muscles of the vagina relax and loosen, which may prevent discomfort. Many women find it helpful to breathe slowly and steadily during the examination.

I'm very small and have tiny feet—will that be a problem when I give birth?

In the past, doctors used to measure a pregnant woman's feet to assess her likelihood of needing a cesarean section, since small feet were thought to indicate a narrow pelvis. Although there is some truth in the fact that small feet generally indicate that a woman is small-framed and therefore likely to have a small pelvis, small women also tend to grow small babies in proportion to their pelvic size. True cephalo-pelvic disproportion (CPD), where the baby's head is too large to fit through the pelvis and be born vaginally, is relatively rare.

During labor there are other factors that help you deliver your baby. The pelvis is not a fixed structure and the hormone relaxin helps to soften the ligaments that hold the pelvic bones together to help the pelvic bones to move to accommodate the baby. Also, your baby's head is designed to mold into shape. The skull is made up of separate bones that are able to overlap each other slightly in order to reduce the overall size of the head as it travels through the pelvis during labor. This is a normal part of the birth process. Labor positions also affect the dimensions of the pelvis. For example, squatting can increase the internal measurements of the pelvis by around 30 percent. Sitting, or lying on your back can actually reduce these measurements by restricting the natural backward movement of the tailbone (coccyx) during birth.

The doctor's office seems so busy—how can I get answers to all my questions?

This is a common problem. Doctor's offices are often very busy. As a result, most book only a 10- to 20-minute appointment for each woman—barely enough time to go through the basic physical checks. However, it is important that your questions are addressed and it may be helpful to write them down so that you remember what you want to ask. If your health-care provider doesn't have time to discuss the issues during your appointment, ask if a longer visit can be scheduled for the next time. Or you may find too that other sources of information such as books, pamphlets, websites, or other health-care professionals may be useful.

It is a crucial part of your prenatal care that you feel comfortable with your health-care providers and are given the opportunity to discuss any questions you have or issues that arise.

I'm four months' pregnant and haven't had many appointments. Will they get more frequent?

Yes, you will find that your prenatal appointments become more frequent as the pregnancy progresses. If you develop any complications, additional appointments would be arranged according to your needs. The schedule of prenatal appointments differs slightly depending on your doctor, but as a general rule you can expect an appointment at the following stages of pregnancy: one to two appointments by 12 weeks of pregnancy, and then appointments at 16 weeks, 20 weeks, 24 weeks, 28 weeks, 30 weeks, 32 weeks, 34 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, and if, your baby is overdue, 41 weeks.

I want a home birth. Will this make a difference to my prenatal appointments?

If you want your midwife to perform a home birth, you should make certain that she is qualified as a Certified Nurse Midwife (CNM) and that she has privileges at a nearby hospital. In the event that complications arise during your delivery, you may need to be transported to the hospital for additional assistance with the birth.

In most cases, women planning a home birth should have the same type of prenatal care as any other healthy pregnant woman in regards to frequency and location of prenatal appointments. Midwives in some areas may provide a home visit toward the end of the pregnancy if a woman is planning a home birth. This is helpful since it offers the midwife an opportunity to assess whether or not your situation is appropriate for a home birth. For example, if you are expecting a multiple birth, or if you have had complications during your pregnancy, a home birth would not be recommended. If your midwife cannot offer you a home visit to discuss the arrangements for a home birth, you should be given an opportunity to talk about it together during your prenatal care.

Is it OK to bring my partner with me to the prenatal appointments?

It is absolutely fine to bring your partner with you to some or all of your prenatal appointments. It is a good way for him to feel involved in the pregnancy, and also gives him an opportunity to ask questions that he may have.

As an expecting mother, you may be allowed time off work to attend prenatal appointments. However, your partner may not have this right, which may pose a problem since most doctor visits happen during the day. Another way to involve your partner in the pregnancy is to attend birth preparation classes together. Classes are often held on the weekends or in the evenings to make it easier for partners to attend. This gives you both a chance to find out more about labor and birth and about baby care after the birth.

When will I hear my baby's heartbeat?

Your baby's heart starts beating around 20 days after conception, and can be seen on an ultrasound scan at about six weeks of pregnancy. It is usually not until around 12 weeks of pregnancy that it is possible to hear the heartbeat with a handheld monitor, known as a doppler, because it is around this time that the uterus starts to grow upward out of the pelvis, which makes it easier to detect the heartbeat. The first time your baby's heartbeat can be heard also depends somewhat on your build; if you are very slim, it is usually easier to find the baby's heartbeat than if you are overweight.

Will my midwife or doctor deliver my baby?

Doctors and midwives realize that it is important for a woman to develop a relationship with them so that they feel supported and able to ask questions, and continuity of care is provided if possible. However, how many health-care providers you meet in pregnancy, labor, and birth and the postpartum period depends on the doctor's practice and hospital you have selected. Depending on your situation and the practice, you may meet a variety of different midwives during your prenatal care. When you go into labor, the midwife “on call” that day will be the one who supports you throughout the labor and the birth.

Prior to your pregnancy, or in your last trimester, it is helpful to discuss care options with the doctors or midwives at your practice. If one-on-one care is of critical importance to you, then you may benefit from choosing a smaller practice.

I've only just found out I'm pregnant and I must be at least four months. What should I do?

One of the first things you need to do is investigate the options for prenatal care that exist in your community. Decide what's important to you: location and proximity to your home or work; one-on-one care with a smaller practice; availability of midwives? Don't be afraid to interview prospective health-care providers, and ask them about their on-call schedule for doctors and midwives and hospital affiliation.

Call to schedule an appointment where you will see a doctor or a midwife. You should also begin a folic acid supplement immediately, and review your diet . Depending on the number of weeks of your pregnancy, you may be due an ultrasound. Most practices offer a scan around at 20 weeks, or earlier, depending on your circumstances. You will be offered a range of blood tests and should be aware of their purpose before consenting. Each practice may have a slightly different schedule for care. The earlier you schedule the better, so that you do not miss out on any aspects of prenatal care.