Overview

Prenatal care is healthcare from a medical professional for you and your baby during pregnancy. It is well established that women who receive prenatal care are more likely to have healthy infants. Your doctor or midwife is your trusted partner and has education about all of the intricacies of pregnancy and birth. An important point to keep in mind is that you are in complete control over what happens and what procedures your doctor or midwife performs throughout your prenatal care. You can expect to have somewhere around 14 appointments throughout your entire pregnancy. The time you spend with your doctor or midwife will shape the tests you take, the procedures your care provider performs, and the preparation for your birth. Learn what to expect at each appointment and how to navigate prenatal care confidently.

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What is Prenatal Care?

What is prenatal care? Prenatal care is healthcare for you and your baby during pregnancy. The main goal of prenatal care is to improve pregnancy outcomes. It is well established that women who receive prenatal care are more likely to have healthy infants. The American College of Obstetricians and Gynecologists has an in-depth document with guidelines for prenatal care. These guidelines outline everything from tests to patient education. The doctor or midwife you see for your prenatal care is your partner throughout your pregnancy, birth, and postpartum.

Your Prenatal Care Options

Three things drive your available options for prenatal care. Those are your financial ability, the venue where you want to give birth, and your primary care provider.

Financial Ability and Health Insurance

Your financial ability to cover costs associated with certain care providers or venues may limit your prenatal care options. If you have health insurance, your insurance company may dictate what providers or services are covered.

Fair Health is a non-profit that collects data on health insurance in the United States. They released data from 2017 on how much it costs to have a baby in each state. The average cost for a vaginal birth with insurance is about $6,500, and without insurance is $12,000. The average cost for a cesarean birth with insurance is $9,300, and without insurance, that cost was an average of $16,500.

If you have insurance, find out what your health insurance will and will not cover. You do not want to plan everything with a care provider, only to determine that your insurance does not cover them. If you do not have health insurance, there are resources available to help you access prenatal care. For more information on understanding how health insurance works see this article.

Your Birth Venue

If it is important to you to have your baby at a particular hospital, birth center, or home, you need to work with a care provider who can attend your birth at that venue. I encourage you to explore some options as to where you want to have the birth of your baby. If you are open to it, check out your choices to have a home birth or visit a birth center. Keep an open mind and visit several places before making a decision. It is easy to have preconceived notions that can be wrong about what a particular hospital or birth center will be like.

The Importance of Your Care Provider

Your health insurance or your birth venue may limit your options for a care provider. Or your choice of care provider may drive your decision about where you give birth. Your primary care provider is the cornerstone of your prenatal care and birth experience. This is your expert resource that you will be working with throughout your pregnancy to make crucial decisions. You need to be comfortable with and trust your care provider. That is more important than their qualifications, where they went to school, and how many babies they have delivered. You need to see them as an integral member of your team, and most importantly, you need to trust them and be comfortable with them. 

Choosing Your Care Provider 

Choosing your care provider is more nuanced than having a midwife for a home birth or an OB/GYN for a birth at a hospital. There is a pretty strong argument that midwife-led care is more of a holistic approach and is more patient-focused. Stereotypically, this may be true, but there are some amazing OB/GYNs out there. The only way to tell whether a particular person is a right fit for the pregnancy and birth you want is to ask questions and shop around. Ultimately, who your care provider is will significantly impact your experience and how your baby enters the world. 

For more information on choosing or changing your care provider see this article. There is also a list of potential questions you may want to ask when finding the right doctor or midwife.

Your Role in Prenatal Care

You play the primary role in your prenatal care. You should seek prenatal care with a medical professional. They are your trusted partner and have education about all of the intricacies of pregnancy and birth. An important point to keep in mind is that you are in complete control over what happens and what procedures your doctor or midwife does throughout your prenatal care. Even if a care provider suggests something, you have an ultimate say. If you have reservations about the safety of an intervention, you can decline it. If your care provider recommends a test you do not wish to take, you do not have to take it.

Informed Consent

Every aspect of your care should come with proper informed consent. I hope you are working with someone thoughtful and considerate about informing you of all of the evidence, pros, cons, and options available.

Organizations within the birth community have guidelines on informed consent. The American College of Obstetricians and Gynecologists’ opinion acknowledges that there are practical difficulties with ensuring the kind of communication necessary for informed consent. The first limitation they address is the limitation of time, which plays a significant role in this. It is difficult to take the time to discuss procedures at length when you are limited to 15 minutes or less for an appointment. 

The North American Registry of Midwives outlines the components of informed consent as Shared Decision Making and Informed Consent. I like their emphasis on shared decision-making because that is what your prenatal care is. You are working with your doctor or midwife to make shared decisions. This is a two-way street. 

True informed consent means that you fully understand the procedure, intervention, or treatment, that you are made aware of all of the risks and benefits, and that you have the choice to opt-in or opt-out. The last part of that is tricky. The truth is that you can opt out of anything. This includes ultrasounds, vaginal exams, the glucose tolerance test, genetic testing, testing for GBS. For a doctor or midwife to honestly give you a choice can be challenging because they, and the entities like hospitals they work for, have policies about what is “required” and routine. From even my personal experience, I know that it doesn’t always feel like you have a choice, but it is so vital that you know you do. You always have a choice, and that is a critical component of true informed consent. 

Frequency of appointments 

Whether you see a doctor or a midwife, your visits follow a typical schedule. Your first appointment is around week 8, or later if you did not realize you were pregnant early on. For the first and second trimesters, your visits are every four weeks. Starting in the third trimester, at week 29, you will have an appointment every other week. You see your care provider weekly for the last month or so of your pregnancy, beginning in week 36. In total, you can expect to have around 14 appointments throughout your entire pregnancy. If you are high-risk or have special considerations, you may have more frequent visits.

The Length of Appointments 

The average length of an appointment varies significantly based on your care provider. Typically, with an OBGYN, your first appointment is the longest and can be up to an hour. After that, appointments are only about 15 minutes. That means you are spending only about 4 hours and 15 minutes with your doctor leading up to your birth. Different care settings may have longer appointment times. Birth centers or independent midwives tend to allocate more time available for each appointment. You may also have the opportunity for group appointments or a centering pregnancy model for appointments, usually around 60-90 minutes. While these appointments are longer, you are sharing the time with other expecting mothers. 

Appointment Routines

There are routine things that you can expect to happen at each checkup. Your care provider will be checking on your health, your baby’s health, and answering any questions you have.

Weight

The vast majority of care providers will ask you to step on a scale at each appointment. Doctors and midwives look at your weight gain throughout your pregnancy as a measure of your overall health. Excessive weight gain or not gaining enough weight during pregnancy is associated with newborns’ low and high birth weights, preterm delivery, gestational diabetes, preeclampsia, cesarean birth, and postpartum hemorrhage. Your risk for these complications is lower if you gain a healthy amount of weight during your pregnancy. 

Your care provider bases the range of weight they expect you to gain on your pre-pregnancy BMI (body mass index). The American College of Obstetricians and Gynecologists adopt their recommendation on pregnancy weight gain from the Institute of Medicine. They base guidelines for the range of weight you should gain on your pre-pregnancy BMI (body mass index).

Underweight BMI <18.5, 28-40 lbs 

Normal weight BMI 18.5-24.9, 25-35 lbs 

Overweight BMI 25-29.9, 15-25 lbs 

Obese BMI >30, 11-20 lbs 

In the first trimester, you should only gain a few pounds. You should experience a steady, gradual weight gain throughout your pregnancy in the second and third trimesters. You can expect around 1 pound per week if you start underweight or at a normal weight, and half a pound a week if you are overweight or obese. 

Weight is only one measurement, and most women are not gaining weight within the suggested ranges. One study that examined over 18,000 pregnancies found that just 25.8% of women gained weight within the recommended ranges, with 21.3% gaining less and 52.9% gaining above. This was across the board for all women regardless of their pre-pregnancy weight.

Checking on Your Baby

In addition to checking on your health, your care provider will also check the health of your baby.

Heartbeat

This is done by listening to the baby’s heartbeat. The heartbeat can be heard in several ways, from doing an ultrasound, using a Doppler to detect the heartbeat with soundwaves, or using a simple stethoscope.

Measuring Your Belly

In the second half of your pregnancy, your doctor or midwife will also measure your belly. They take the distance between the top of your pelvic bone to the top of your uterus (called a fundus). After about week 24, the length in centimeters will roughly match up to the number of weeks along you are. It is not uncommon to measure a week off, so don’t stress if the measurement doesn’t line up exactly.

Your Baby’s Position

As you get closer to your due date, your doctor or midwife will palpitate your belly or use a doppler or ultrasound to determine your baby’s position. The main reason that your baby’s position is important is that most providers do not have experience in vaginal breech birth. The majority of breech babies in the United States are born via cesarean.

Please do not stress out over your baby’s position, especially before the third trimester. A group of researchers analyzed over 18,000 ultrasounds to determine the frequencies of presentations with gestational age. It is not surprising that most babies were not head down early on but did move into that position as pregnancies progressed. At 22 weeks, only 47% of babies are in a cephalic presentation, meaning they are head down, which increases to 94% at 36 weeks. Up to 24% of babies in a breech presentation will move into a cephalic presentation after 36-37 weeks.

For more information on how to determine your baby’s position, see this episode. If your baby is breech, you may be able to try an external cephalic version to turn them. If you want to see the evidence on optimal fetal positioning and spinning babies, see this episode.

Questions

Your meetings with your doctor or midwife are an excellent opportunity to ask questions. There is no such thing as a stupid question. In between appointments, keep a list of questions that come up. You can do this on a piece of paper or in a note-taking app on your phone. When you have your next visit, bring your list to be sure to get all of your questions answered. If something comes up, you cannot wait until your next appointment; please do not hesitate to call or email your doctor or midwife. 

Jotting down a few notes during an appointment can go a long way in recalling what you talked about later. Doctors and midwives are medical professionals who use a lot of terms that may be unfamiliar to you. If you are asking questions, be prepared to take some notes when they answer. 

Ask them to clarify if you don’t feel like you get a clear answer. If you want to know more information, ask them to explain it further. You have limited time with your doctor or midwife, and please take advantage of it.

Know What to Expect Next Time

At the end of each appointment, ask what you can expect at the next appointment. You can also always call the office and ask someone ahead of time. The alternative is that you are put on the spot to opt into something. It is much easier to make informed decisions when you are not pressured and have the time and the space to explore your options and think through what is best for you and your baby. If you are looking for information on a particular subject, chances are there is an episode of the Pregnancy Podcast that dives into the evidence on it. 

Prenatal Tests

A big part of your prenatal care is testing for conditions in both you and your baby. Remember that the highest probability is that you and your baby are healthy. 

Screening Test vs. Diagnostic Test 

It is crucial to understand the difference between a screening test and a diagnostic test. A screening test does not diagnose a condition; it only signals that further testing is needed. It can be devastating to get screening results back, showing your baby is at a higher risk for anything. Please understand that you don’t know anything for sure until you have a diagnostic test. 

Non-invasive vs. Invasive Tests 

You can further classify tests as non-invasive or invasive. Non-invasive tests are those that do not have a risk for you or your baby. These typically use a urine or blood sample from you. If you have anxiety about needles, you may not consider a test drawing your blood to be non-invasive. If the thought of having blood drawn makes you uneasy, let your doctor or midwife know. You can ask for someone who has a lot of experience taking blood, so you do not have a first-day intern sticking you with a needle.

Blood Pressure, Urine, and Blood Tests

You can expect to have your blood pressure taken at each visit. High blood pressure is associated with preeclampsia, preterm birth, and placental abruption.

Your care provider will ask for a urine sample several times during your pregnancy. The frequency of urine samples depends on your provider and your health specifics. Urine samples test for sugar, which is a sign of gestational diabetes). They also test for protein, which can indicate a urinary tract infection, kidney damage, or some other disorders. You can also expect a few blood tests. These will check your blood type, infections, or diseases, checking your blood count for anemia, some tests, later on, can even indicate whether your baby has any abnormalities. 

Prenatal Tests

While there are many routine tests, just because something is routine does not mean it is mandatory. Many expecting mothers show up to a prenatal appointment and learn they are taking some type of test at that time. If you know ahead of time what tests options will be available, you have the opportunity to look into the pros and cons beforehand. A good place to start is with the episode on prenatal testing basics.

Testing for Chromosomal Abnormalities

Your care provider may offer several screening tests for chromosomal abnormalities. These tests all require a blood sample from mom and may also incorporate results from an ultrasound. The cell-free DNA or NIPT (Non-Invasive Prenatal Test) can be as early as ten weeks. The first-trimester screen is between weeks 11-14. The quad screen or triple screen tests are between 15-20 weeks. More information on the first-trimester screen, quad screen, and triple screen tests is here.

If the screening test results indicate your baby is at high risk, you may take an invasive diagnostic test. Invasive testing includes a CVS at 10-12 weeks, amniocentesis at 15-20 weeks, or cordocentesis after 17 weeks. Invasive tests do involve a risk to your baby, and you can learn more about these tests here.

Gestational Diabetes Testing

Gestational diabetes affects 6-7% of pregnancies. While this may not affect you, the testing will because it has become standard to test all pregnant women, even if you do not have any risk factors. 

GD is a type of diabetes that just occurs during your pregnancy and goes away after the birth of your baby. The Glucose Challenge Screening is a preliminary screening test performed between 24-28 weeks. The results from this screening test may indicate further testing. There is a full episode with in-depth information on gestational diabetes testing.

Group B Strep

Group B streptococcus is a type of bacterial infection. This bacterium naturally lives in the gastrointestinal tract. GBS is common and is in 10%-30% of pregnant women. Once you have this bacterium, it does not mean you will always have it, and it can come and go. Most women with group B strep do not experience any symptoms, and usually, this is not a big deal. However, it can create complications for you when you are pregnant and cause severe complications if you pass it to your baby. In the United States, it is standard practice to test all expecting mothers in week 36 or 37 for group B strep. The GBS test uses a swab of your vagina and rectum. For more information on group B strep, see this article.

Finding Out Your Baby’s Sex

You can find out the biological sex of your baby from an amniocentesis or CVS (chorionic villus sampling) test, a NIPT (non-invasive prenatal test), or an ultrasound. You also have the option not to find out and be surprised. There is a full episode with lots of information on finding out your baby’s sex.

Opting In or Out of Tests

Remember, you always have a choice. You may also have options of how your care provider performs tests. Before you choose to opt into any prenatal test, especially an invasive test, there are several questions to consider.

  • Will the information from the test shape your prenatal care? Some prenatal tests detect problems you can treat during pregnancy or that will need immediate treatment after birth.
  • What will you do with the test results? Of course, getting results that everything is normal is what you want, and it can be reassuring. If the prenatal test results indicate that your baby may have an abnormality, you may have tough decisions to make.  Some people will use test results to decide whether they want to continue the pregnancy, and some people who wouldn’t consider that to be an option may want to know about any abnormalities ahead of time so they can plan for their baby’s care in advance.
  • How accurate are the results of the test? No prenatal test is always 100% accurate, and the rate of inaccurate results, known as false-negative or false-positive results, varies from test to test.
  • What are the risks? You want to know if there are any risks associated with a test before taking it. This allows you to weigh the risks of the test against the benefits of knowing the results.

Keep open communication about prenatal testing with your care provider.  Talk about the risks and benefits before opting for a test. You may also want to meet with a genetic counselor who can help you understand the results. They can also walk you through how a condition would impact your baby’s life and get more into detail on possible treatment options.

Prenatal Interventions

In addition to tests, you may also have other interventions or procedures during your prenatal care.

Vaccines 

The vaccines that the American College of Obstetricians and Gynecologists have historically recommended during pregnancy are the flu vaccine and Tdap. Some expecting mothers and care providers may choose to avoid a flu shot during the first trimester because this period is critical to development. The Centers for Disease Control says that you can get a flu shot during any trimester. One study showed that the influenza vaccination at any time during the second and third trimester of pregnancy, but at least 15 days before delivery, creates passive immunity. 

Tdap stands for Tetanus, Diptheria, and Pertussis (aka whooping cough). ACOG recommends the Tdap vaccine for all pregnant women during each pregnancy. It is given via intramuscular injection in your upper arm in the third trimester. Typically this is given between 27-36 weeks to provide you with adequate time to produce antibodies and pass them to your baby before birth.

ACOG currently recommends that all eligible persons, including pregnant and lactating individuals, receive a COVID-19 vaccine. For more information on the COVID-19 vaccine during pregnancy, see this episode which dives into the clinical trials. Please discuss it with your doctor or midwife if you have any questions or concerns about the COVID-19 vaccine or any other vaccine during pregnancy.

Ultrasounds and the Anatomy Scan

You can expect to have at least one or likely multiple ultrasounds during your pregnancy.

An early ultrasound is usually done with a transvaginal scan in the first trimester and accomplishes two things. First, it confirms that you are pregnant. Second, it also dates your pregnancy, so you know your baby’s age. Your care provider will use it to verify a heartbeat, measure the crown-rump (from the top of the head to their bottom) length or gestational age, confirm molar or ectopic pregnancies, and assess abnormal gestation. 

It is routine for expecting moms to get an ultrasound anatomy scan in the second trimester. Generally, you can expect to have this done at 18-20 weeks. The second-trimester anatomy scan ultrasound diagnoses fetal malformation, structural abnormalities, confirms a multiples (twins) pregnancy, verifies dates and growth, confirms a miscarriage, identifies excessive or reduced levels of amniotic fluid, and overall evaluates your baby’s well-being. During this ultrasound appointment, your baby will be measured from crown to rump, around their middle and head. Since this is an anatomy scan, the ultrasound technician will be looking specifically at the heart’s four chambers, the kidneys, bladder, stomach, brain, spine, and sex organs.

If you are interested in researching the safety of ultrasounds or considering a 3-D or 4-D scan, see this episode.

RhoGAM

Suppose your blood type is Rh-negative and your baby’s father is Rh-positive. In that case, your baby could be either positive or negative. This means there is the possibility of incompatibility when your blood is exposed to your baby’s blood. Normally, this doesn’t happen. An injury, like a car accident, could cause your blood and your baby’s blood to come into contact. This can also occur if you have a miscarriage if you have an external cephalic version, a procedure to try and flip a breech baby, with an invasive test like amniocentesis or CVS, or during the birth process with interventions like using forceps, a vacuum, or a cesarean section.

RhoGAM is given as a shot at 26-28 weeks to prevent your immune system from attacking your baby’s blood. Rh immunoglobulin finds Rh-positive blood cells and prevents the creation of RH antibodies. It works similarly to a vaccine. If you have a negative blood type, please check out this episode on the pros and cons of RhoGAM.

Vaginal Exams

As you get closer to your due date or during labor, your doctor or midwife may suggest examining your vagina to measure your cervix. Results of a vaginal exam may be useful, but they cannot accurately predict when labor will start or how much longer you will be in labor. You could be dilated to 2 cm for weeks before you go into labor and still go past your due date. If you are in labor and progress from 2 to 3 centimeters in an hour, there is no guarantee that you will be at 4 centimeters in another hour. You may still be at 3 centimeters, or you could be at 6 centimeters.

You may want to know the status of your cervix purely out of curiosity, even after you understand that this cannot accurately predict when or how long you will be in labor. If you are considering inducing labor, understanding whether your cervix has begun to dilate and efface may indicate that you have a higher probability of a successful induction. You can see all of the evidence on vaginal exams here.

Birth Plan

If you are creating a birth plan, you must work with your care provider during your prenatal care to ensure they are supportive of the birth you want. A birth plan is more than a piece of paper you hand to your care provider. A birth plan is a process you go through with your doctor or midwife to prepare for the birth experience you want. If you aren’t 100% clear on anything about your birth, now is the time to bring it up. Make sure your care provider is clear on what you want and that they support your wishes. If there is anything you do not see eye to eye on, talk about it. If you have concerns, bring them up. You and your care provider are on the same team, and you will not get the birth experience you want if you plan without them. 

Trust Your Gut and Don’t Wait for the Next Appointment

The majority of your visits will be uneventful, which is a good thing. If you think that something may not be right and would like to see your care provider before your next visit, call them and make sure they get you in. Trust your instincts and listen to your body. If you are paying attention, your body will let you know when something isn’t right, and if you are worried about anything, it is worth it to contact your doctor or midwife to give yourself some peace of mind. Stress doesn’t do your body, or your baby, any good.

Including Your Partner

I am a massive advocate of involving your partner in your prenatal care and ideally attending all of your prenatal appointments. Hopefully, if you do not have a partner, you have a friend or family member who can step in to be there for you. There are many benefits of having your partner join you for appointments. It allows them to ask questions and get educated about pregnancy and birth. It can help them feel more connected and excited about having a baby. Plus, they can help advocate for you.

Appointments and COVID-19 

COVID-19 has created some new policies and procedures for prenatal care. You may have fewer personal appointments or meet with your doctor or midwife virtually. If you are going in for an appointment, please ask for any specifics you should know ahead of time. It will help you to know if you need to wear a mask if you need to call ahead before entering the office, and whether they allow your partner or a support person to accompany you. 

Due to COVID-19, many care providers request that you do not bring anyone with you to appointments. If you have an in-person appointment alone, you can always get your partner on speakerphone or FaceTime to be there. It isn’t the same as having them in the room, but it is better than nothing. 

If you have a virtual appointment, please include your partner. Different providers are using different platforms, and if you are using a new platform that you have not used before, please log in a few minutes early to test your audio and video. If your partner or a support person will be joining you from another location, ask if they can use the same link or need their own. 

Dental Care

One last aspect of prenatal care you may not consider is dental care. The American College of Obstetricians and Gynecologists recommends that you see a dentist during your pregnancy for cleanings and x-rays. Approximately 40% of pregnant women in the United States have some form of periodontal disease. Periodontal or gum diseases range from simple gum inflammation to serious disease that significantly damages the soft tissue and bone that support the teeth. In the worst-case scenario, you can even lose teeth. This becomes even more of a problem when you are pregnant because evidence shows periodontal disease is a risk factor for premature labor and your baby’s low birth weight.

You are in Charge

The biggest takeaway I want you to have from this episode is that you are in charge. No matter what type of care provider you use or where you plan to give birth, you are the ultimate decision-maker. You can expect to have somewhere around 14 appointments throughout your entire pregnancy. On 14 days, you will see a doctor or a midwife, that’s it. For the other 260, some days that you are pregnant, it is just you and your baby.

Remember that you are hiring your doctor or midwife. You also can fire them and change your care provider if you don’t feel like you are getting the attention or support you need. Switching providers is easiest the earlier you are in your pregnancy. I genuinely hope you find the right provider and that you feel supported during every prenatal appointment and confident when you are navigating pregnancy outside of their office.

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