“Prenatal Care, Part Two: What to Expect in Each Trimester” – with Dr. Sara Kostant

Dr. Nathan Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health, at all stages of life. I am your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Sarah, welcome back to the podcast. We’re doing our second of back-to-back on prenatal care, and last week we sort of covered the goals of prenatal care, and an overview of prenatal care, and we figured that this week we’re going to go into a little bit more of the specifics, you know, the nitty-gritty of prenatal care, what to expect.

So, someone shows up for the first prenatal visit, and I know we had a whole podcast on the first prenatal visit, but just in general, what are the things that we’re doing at the first prenatal visit? Or what should people expect to happen, I guess, during the first prenatal visit?

Sarah: Well, besides just getting to know the patient, which again, we talked about on our podcast, on the first visit, one of the most important things is just establishing the gestational age, and ultimately what the due date will be. By due date, I mean when that person will be 40 weeks pregnant. And it doesn’t mean that that’s when that person is going to deliver the baby, but it helps us to establish landmarks throughout the pregnancy, timing other testing. The way we do that is first I’ll ask patients when their last…the first day of their last period. That’s probably the most common starting point. And based on that, we can at least get an initial calculation of how far along we think that person should be.

Now, that isn’t always an accurate way to determine how far along someone is, because many women have very irregular menstrual cycles. So their last period might have been eight weeks ago, but they may actually not be, you know, eight weeks pregnant, they may be five weeks pregnant, or six weeks pregnant. So in our practice, and in many practices, we couple that with also doing an ultrasound to confirm the gestational age. And sometimes it just confirms what we already thought, but sometimes we’re off, just by looking at the last menstrual period. And I’ll tell someone, you know, actually you have a fetus, there’s a heartbeat, this looks good… Which again, then the other part is confirming that the pregnancy is viable, that it’s continuing, but I’ll tell them you’re actually six weeks pregnant instead of eight weeks pregnant.

So, that’s probably one of the first things. And then, again, I mentioned, you know, checking for a heartbeat. Sometimes patients will come in, and actually will realize that they’re much earlier than we thought. Like there is a pregnancy, but we can’t even see a fetus yet, you know? There’s what we call a gestational sac in the uterus, so we know that the pregnancy is in the uterus, which is another thing we want to establish, we want to make sure it’s not a tubal pregnancy, but we don’t see a fetus yet. And in those cases, we’ll have someone come back in one to two weeks, and repeat the ultrasound.

So, those are the things that can happen when we’re trying to figure out the gestational age, either we confirm it, we sometimes change it, or we have to have patients come back if they’re earlier than we had thought. And again, everyone’s different. Not everyone has an exactly 28-day menstrual cycle. So there are quite a few times that we end up, what we call re-dating the pregnancy, and you know, that’s fine.

Dr. Nathan Fox: Yeah, and this definitely varies around the country, even around just New York, or around the world, but pretty much every time you show up for a new pregnancy visit, one of the first things someone is going to ask you is, when was the first day of your last period? That’s like a universal question. I guess unless you had IVF, and we know the second that you conceived. Yeah. But otherwise, you know, they’ll ask that.

And then, you know, in our practice, we do that ultrasound pretty much routinely at the first visit. Like you said, it’s really helpful for knowing are we correct with the due date? Is there a heartbeat? Is it singleton or twins, you know? All these things that we’re going to learn right away, but that’s not always done. I would say, actually, most practices in the U.S., at least, probably don’t do an ultrasound at that initial visit, just because of resources. You have to have ultrasound machines, and someone capable of doing it, it’s a whole thing. So not everyone’s going to get that, and maybe later on, they’ll get an ultrasound that might confirm or potentially change what was initially thought. But we do it at the first visit. I’m a big fan of it, if you have, you know, the resources available to do it.

But that’s really, I agree, sort of like the first thing we’re doing. Because, you know, someone comes in, they’re all excited, or not always excited, but whatever, they’re pregnant, and we just like to be sure, okay, let’s make sure we’re all on the same page here, like you’re as far as we think you are, it is a viable pregnancy, it’s only one or it’s two…like, so we all sort of start at the same place, and so that’s done. What else is done at the first prenatal visit, besides sort of establishing those features?

Sarah: So, getting to know the patient not just socially, but also just their history, going through their medical…even their non-obstetric and gynecologic history, allergies, prior surgeries, medical history…because all of these are things that can impact their care. One of the things I’ll always ask patients is if they and their partner, or if they ended up using a sperm donor, or got pregnant through infertility assistance, if they did genetic carrier screens. Because if they did, you know, great. If not, that’s something that I’ll talk about as well, and that’s a whole other topic to go into. But that’s one of the things that we’ll go over, and also, even just briefly introduce just the genetic testing that’s available in the pregnancy.

And then, there’s a lot of counseling involved just on, you know, what we kind of generally call, like, you know, dos and don’ts in pregnancy. More emphasis on the dos than the don’ts. We don’t want to…there’s still a lot… And also, even, you know, getting rid of some myths that some people have about things they can’t do. But going over, you know, exposures that they should try to avoid, food, chemical exposures, you know, activity, you know, depending on the situation… There aren’t that many activity restrictions usually when patients come for their first visit. We’ll talk about things like travel in pregnancy, and we’ll also talk about nutrition and vitamin supplementation, and you know, what type of prenatal they should be taking.

One of the things, you know, some of our patients, we’ll recommend they take a low-dose aspirin supplement, and we’ll talk about that too, and the reasoning behind it. So, that’s kind of just, like, a basic summary of probably the most common things we… And obviously, answering any other questions that I haven’t covered.

Dr. Nathan Fox: Yeah, I mean the first…the beginning of pregnancy, you know, prenatal care is very front-loaded and back-loaded, you know? In the front-loaded, at the beginning part of pregnancy, the first visit, or the first two visits, or the first three visits, again, everyone does it a little different, every office does it a little differently, there’s a lot more that happens, you know? When we schedule an initial prenatal visit, we schedule it for an hour. That’s a pretty long doctor visit. Most doctor visits you have, and pretty much any doctor you see are not going to have an hour on their schedule. It’ll be somewhere between five minutes and maybe thirty minutes. But we schedule an hour, because there’s a lot of talking, we ask a lot of questions, because there’s a lot of information we need to get. And obviously, we listen to and answer a lot of questions, because a lot of people come into pregnancy with a lot of questions.

Now, it is possible that someone’s first pregnancy, that’ll be longer because we may not know as much about them, and they have never been around, or you know, through this before, so they may have a lot of questions. And yes, it’s possible that in the second pregnancy, both of those might be shorter because again, we know each other. Sometimes in the second pregnancy it’s longer, based on what happened in the first pregnancy, right?

Sarah: Right.

Dr. Nathan Fox: So, we always schedule an hour for the first visit. And I would say in the beginning of pregnancy, the visits tend to be a little more frequent as well, because there’s more stuff to talk about, more things come up. Obviously, there’s a lot of symptoms in the first trimester for people, they’re tired, they’re nauseous, they’re weak, all these things…and there’s a lot of blood testing we do. We do a lot of blood testing, routine stuff, you know, general health stuff, you know, are they immune to things, and there’s all the genetics. So there’s a lot that happens in the first trimester, so I would say expect several visits, possibly several blood draws, possibly several ultrasounds, a lot of time talking back and forth, and that sort of takes you through the end of the first trimester.

And again, the things we’re trying to do is assess, you know, is this person sort of healthy going into the pregnancy? And if not, if there are some issues, you know, how do we have to alter our typical prenatal care plan, you know, based on what’s going on in her life and her health? Also, you know, we’re trying to assess, again, is it viable? Is the pregnancy progressing as expected in the first trimester? Again, there are a lot of people who miscarry in the first trimester, unfortunately. It doesn’t mean anyone did anything wrong, or there’s anything wrong with you, but that’s something that happens, and so we like to follow it, and make sure everything’s going okay. And then, once you get out of the first trimester, things tend to settle down, so to speak, in terms of frequency.

So someone gets through the first trimester, and they had all the visits, they had all the questions back and forth, they got everything answered, they’re hopefully a little less nauseous, thank God they haven’t miscarried, everything looks okay, we did the genetic testing, they sort of went through that okay. What happens in the second-trimester prenatal care-wise? So we’ll say around 12-ish weeks through, let’s say, 24 to 26 weeks.

Sarah: So at about 12 weeks, as you mentioned, most patients will have an ultrasound called the nuchal translucency ultrasound, and that’s part of the genetic testing, and that kind of closes the first trimester. Usually after that, the visits are about every four weeks. And again, this can be altered depending on someone’s prior medical or prior pregnancy history. But we have patients return around 16 to 17 weeks for an initial anatomy ultrasound, and then around 20 to 21 weeks for what we call the detailed anatomy ultrasound, and then again around 24 weeks. And depending on their history, they may or may not get another ultrasound to check the size of the baby, or one of us… In our office, we check the fetal heartbeat using an ultrasound, so we can also check the position, and the amniotic fluid. So in our practice, at every visit, patients will see their baby on ultrasound, but not everyone needs to have growth ultrasounds at every single visit in the pregnancy.

So, the visits are about every four weeks. The 16 and 20-week ultrasounds we recommend for all of our patients. They’re longer than the prior ultrasounds, and they’re pretty much, I always tell patients, like, basically a head-to-toe look at the baby, you know, checking the spine… Specifically at 16 weeks, that’s the visit where we get a good look at the spine, make sure that we don’t see any evidence of any spina bifida, neural tube defect, you know? The whole reason that patients have been on folic acid since before, hopefully, before they became pregnant is to prevent that. And then at the 20-week ultrasound, we look at everything again, but at that point the baby’s big enough that we can get a better look at the baby’s heart, and that’s where we make sure that all the parts of the heart look normal, there’s no what we call holes in the heart, no cardiac defects.

And then, once those two ultrasounds are done, again depending on someone’s history, you know they may not necessarily even need another, you know, formal growth…or formal ultrasound to check the size of the baby until, you know, later in the third trimester.

Dr. Nathan Fox: Yeah, I mean, this is also something that varies regionally. I mean, in our practice, like you said, we like to look at the baby head-to-toe both at 16 weeks and 20 weeks. We do that just because, first of all, most people are happy to see their baby, you know, at both times. But also, if there’s going to be a problem, you’re more likely to pick it up if you look twice. Also, if there is a problem, often you’re better off knowing earlier rather than later. But again, since most people don’t have any problems, and thank God most of the time the babies look fine, it’s nice to get that reassurance earlier, and just say, my baby looks great, like, this is fantastic.

For places that do sort of the traditional one anatomy scan around 20-ish weeks, again, that’s how it’s done probably in most parts of the country, that’s fine, you know? That’s how most people do it, and it’s perfectly fine. But then, generally, if that’s what’s going to happen, they’ll have some other tests done around 15 or 16 weeks, like you said, to look for spina bifida. That can be a blood test, or an ultrasound. We do it by ultrasound, but a blood test is sometimes done routinely at 15 weeks. So for some people in the second trimester, their prenatal care is going to be come back around 15 or 16 weeks, and we’ll do a blood draw, and then come back around 20 weeks, and we’ll do an ultrasound. And then at 24 weeks, come back…

Why these things were done every four weeks, again, we talked about this a little last time, it’s just a round number. I think that, again, there’s no magic to four weeks. And some of it is also, you know, what do people want, right? I tell people, like, if you have a lot of questions, you’re just more anxious, and you want to come back every two weeks, and ask questions, and listen to the heartbeat, or again, in our office, since we sort of use an ultrasound to listen to the heartbeat, you know, just see that the baby looks okay, right, like, no problem. We’re happy to do it. And then other people don’t want to do that. They have to travel far to come in, or they’re working, or you know, whatever it might be. So usually, we don’t like to stretch it more than four weeks, just because we like to get a check, make sure the mom’s okay, make sure the baby’s okay, talk about upcoming tests. But some people really want to limit their prenatal visits, and they stretch it a little bit. But we try not to do it less frequently than four weeks apart.

One of the nice parts about prenatal care in the second trimester is usually, this is a time when mom feels the best physically. Not always, but usually this is a time when that sort of post-first trimester stuff like nausea, tired, all those things, and pre-third trimester stuff, like swollen ankles, I’m carrying around this big baby and my back hurts and all that stuff, so frequently they’re in the best mood they’re going to be in the second trimester, which is nice. And I would say the second trimester focuses probably predominantly on the baby more so than the mom, again, because she has fewer symptoms. It’s not a time when people typically get diabetes, it’s not a time when people typically have hypertension, it’s not a time when people typically have…I mean, they could, but they don’t typically have, you know, bleeding, or preterm contractions or stuff. And so, almost…most of the focus at that time is ultrasounds or blood tests, looking at the baby, and making sure the baby’s okay.

So like, the first trimester is like, mom and baby, second trimester…and we’re doing both, but it seems to be focused more on the baby, and fortunately, most of the time it goes well.

Sarah: Yeah, if anything, just going to blood pressure for most patients, their blood pressure actually is a little…that’s probably when it’s the lowest in pregnancy.

Dr. Nathan Fox: Yeah.

Sarah: So for patients that have had issues with chronic hypertension, they tend to do really well then, because their pressure will be under great control. I always say also, the second trimester, when patients want to travel, I’ll say to do it then, because they’re the most comfortable, you know? Again, they’re not at the point where they have the same level of, like, fatigue, and maybe, like, just swelling that they might get, like, at the end of the pregnancy. And also, probably in some ways it is the safest time to travel, because thankfully, hopefully, we don’t expect really anything to happen, you know? The further you get in the pregnancy, even though we don’t expect patients to go into labor at 32 weeks or 34 weeks, it can happen once in a while. And so you’re way away from that when you’re, you know, 22 weeks pregnant, hopefully.

Obviously, there’s exceptions, but provided that the pregnancy is…you know, that we don’t feel a patient’s at risk for a second trimester pregnancy loss, or you know, they don’t have a short cervix, they haven’t had…you now, there’s no evidence of preterm labor, nothing else going on, they haven’t had bleeding, I’ll tell patients that’s the best time, if they want to do a trip, to do it then.

Dr. Nathan Fox: Yeah, I mean, similarly, I told people, you know, anything could in theory happen, at any time, but playing the odds, the chance of some complication happening while you’re on vacation at some random place is much lower in the second trimester than it would be in the third trimester. So yeah, that is typically a time when people are planning what’s called the “babymoon,” I guess. They’ll frequently do it in the second trimester, or the very beginning of the third trimester, again, which is totally fine.

And then, so they get past the second trimester, baby looks good, and now they’re, let’s say 24-plus weeks, let’s say until about 36 weeks… Because I know we had a podcast on the 36-week visit, so let’s say the bulk of the third trimester. So, what happens during those visits? What should people expect at that time?

Sarah: So, the visits are going to start to become more frequent. In our practice, and we did this when I was in training too, there’s usually a 24-week visit, a 28-week visit, and then after 28 weeks, we would start seeing patients every two weeks. And again, going back to why every two weeks, it’s just it’s more often than every four weeks, but not too often.

Dr. Nathan Fox: Right.

Sarah: That’s basically the best answer.

Dr. Nathan Fox: Yeah, it’s an even number. Yeah.

Sarah: Right. Exactly. I think that people tend to have more questions at that time, again, about the end of the pregnancy, and there is more of a chance, as we get further, that “things can come up.”

Dr. Nathan Fox: Right.

Sarah: And one of the things, just to take a step back, we do… One of the big screening tests at this point is screening for gestational diabetes, which we’ll do anytime between 24 and 28 weeks. So we have a lot of patients that just do that at their 24-week visit, they’ll do what’s called a one-hour glucose test, where they’ll take a 50-gram glucose load, and then wait an hour, and have their blood checked. We usually will check complete blood count as well, just to make sure that the platelet count is normal, that that hasn’t started to drop in the pregnancy, and that the patient’s not anemic, and doesn’t need any extra iron above what they may have in their prenatal vitamin.

So that’s done around that time, and again, if the glucose testing shows it is elevated, there’s a confirmatory three-hour test, and so that’s the period of time where we will diagnose someone with gestational diabetes, you know, if they have it. And that will affect, sometimes, the frequency of visits going forward as well. Presuming that that’s normal, you know, maybe someone’s mildly anemic, we’ll recommend eating more iron-rich foods, or start a low-dose iron supplement, then again, the visits will be 28 weeks, 30 weeks, 32 weeks.

I talked about earlier how we don’t routinely do, you know, serial growth ultrasounds, we don’t send patients to check the size of the baby every four weeks, for all of our patients. But usually, in our practice, we have around let’s say 32, 33 weeks, usually recommended a growth ultrasound, just as kind of a check-in with the baby. Occasionally we’ll have some patients that would prefer not to do it, and you know, if they don’t, that’s fine. We typically are measuring the uterus with a tape measure, checking what we call the fundal height, measuring the centimeters from the pubic bone, over the top of the uterus, just to get a basic idea that the uterus is growing as we would expect for the gestational age that the patient is at. So if I have a patient who’s 30 weeks pregnant, I would expect that measurement to be roughly 30 centimeters, give or take about three centimeters in either direction.

Again, it’s not an extremely accurate measurement, but for a “low risk patient,” meaning a patient that doesn’t have gestational diabetes or high blood pressure, where we don’t think that particular patient is really high risk for having a growth-restricted baby, this can be a nice way to at least make sure that the baby is growing in the range that we think is appropriate, without having to do frequent growth ultrasounds. But typically, most of our patients around 32 weeks will get one, and if that one is normal, like the baby’s in normal range size, they may not get another growth ultrasound the rest of the pregnancy, unless, again, there’s some other medical indication for it.

Dr. Nathan Fox: Yeah, it’s so funny, you were talking about the going from every four weeks to every two weeks, and they’re just nice, round, even numbers. Sometimes, you know, we get so used to that, and you know doctors, we’re all a little nuts, you know, and so, like, if I see someone, and their visit’s at 29 weeks, sometimes I just can’t help myself, I’ll say, like, come back in three weeks so we can get you back onto an even number schedule, because I’d rather see you at 32 weeks than 31 weeks, just because that’s how my brain works.

Sarah: Yeah, I’ve kind of done that too [inaudible 00:20:02] there’s some, like, mental thing…

Dr. Nathan Fox: It’s something… Yeah, I don’t know, we’re just…whatever. It’s, yeah, whatever, we have our own…we all have our own issues.

But typically for people in the third trimester, if that blood test is normal around 24 to 28 weeks, you know, they pass their diabetes screen, their blood count is normal, it’s usually the last blood test we’re going to do on people until they’re in labor, and we usually don’t need to follow it up. Again, if there’s either they’re anemic, or there are platelets, or there’s diabetes, fine, then they may have more blood testing, but assuming they pass, that’s typically it.

And again, for me, with the frequency of visits, when I see someone at 28 weeks, I usually give them the choice. I’m like, do you want to come back at 30 weeks, or do you want to, like, you know, come back at 32? I usually say, that’s like my dealer’s choice visit, the 30-week. Some people want to come because, you know, they want to start coming more frequently, and other people, like, want to push that off. And again, if everything’s going fine, that’s okay.

There’s always, in all prenatal care, no matter how it’s done, there is some assessment of is the baby growing well in the third trimester? And how that’s done is going to vary based on, again, location, sort of habits of the doctor or midwife, the risk of the patient, and so, sort of the lowest tech way to do it is, like you said, measure the uterus, and the highest is to do frequent ultrasounds, and everything in between. And we do it differently in our practice based on, you know, the risk of the patient, and other practices do it different, but there’s always going to be some assessment of how is the baby growing. Because that’s really, if anything’s going to happen in that point in pregnancy that’s one of the things. The other is always we check blood pressure to screen for pre-eclampsia, although that’s pretty unusual early in the third trimester, but it’s a possibility.

And then, same thing, like if she’s not complaining of contractions and her water breaking, we don’t do much to assess for preterm labor other than asking, are you having a lot of contractions? But it’s not typically something where that’s how we’re going to find it, you know? “Hey, are you having a lot of contractions?” “Yeah, I feel like I’m in labor.” Like, usually they’re going to tell us first, but okay. And again, it tends to be pretty low-key in that point, sort of like the second trimester.

The one thing that we added a few years ago to our routine prenatal care is we do a formal depression screen, sort of a mental health screen. It’s not just depression, it’s depression and anxiety, but a mental health screen in the middle of pregnancy. Very, very simple, just a couple of structured questions that everybody answers. Again, every now and again we’ll find something that we didn’t know about, and it… But it’s just sort of a reminder for us and for the patients that we always have to consider mental health, and not just physical health, and so ideally, that’s something that we always remember, and maybe one day in our world we’ll all get there. But having these is really a nice sort of, like, formalized way to say, okay, let’s just be sure that you’re okay, and we’re thinking about this, and so we do it at that point also.

And then, one other thing that happens in the third trimester is if your blood type is something negative, you know O-negative, A-negative, B-negative, whatever, you get an injection of something called RhoGAM, for another podcast, and we usually recommend the Tdap vaccine, again, we did another podcast. But that’s the timing that we do it, in the third trimester. So I think, unless I missed anything, or we missed anything, I think that covers us for about around 24 to 34, 36 weeks.

Okay, we had a podcast on the 36-week visit, but just in terms of the prenatal care that happens at 36 weeks, so what shifts, typically? A lot of things change at that point.

Sarah: Well, first of all, the frequency of visits yet again.

Dr. Nathan Fox: Yeah.

Sarah: And at this point for our patients, we’ll usually recommend them weekly, from 36 weeks until delivery. Which I think makes sense, because that’s the period of time when patients are more likely to go into labor, or have their water break first and then go into labor… If blood pressure is going to go up, if someone’s going to develop preeclampsia, it’s much more likely to happen after 36 weeks than any time before that, so weekly visits just give us a chance to check their blood pressure more often. I always talk to patients about symptoms of preeclampsia as well, just between visits, because I always tell them, even if you were just seen two days before, if you have any of these symptoms, you know, and I go over labor symptoms as well, but we’ll see you at any point for a same-day visit.

And the other thing that we always check, and again, in our office, because we check the heartbeat using an ultrasound, we also…it’s very easy to check the fetal position, we make sure that the baby’s in a head down position, or vertex position, as opposed to transverse or breech. And usually, if a baby has been breech or transverse most of the pregnancy, we’ve had discussions with the patient, you know, even around like 34, 35 weeks about that, and options for management, which can include, and again, we may even have a whole podcast on this…

Dr. Nathan Fox: We do.

Sarah: …trying to turn the baby to head first. So it’s usually not a total surprise, but every once in a while a baby will decide at 37 weeks, hey, I want to be breech, and will just flip, and then, again it just gives us a chance to talk to patients about the options. You know, we’ve had patients that baby suddenly became breech, and at 39 weeks we took the mom to the hospital, and talked to her about options for…and tried to turn the baby back to head first.

Dr. Nathan Fox: Right.

Sarah: So, you know, we want to catch these things ideally, so, you know, we don’t necessarily have someone showing up at the hospital, you know, water broke, and the baby’s transverse. And you know, if someone hadn’t been seen in three weeks, it might be less likely…obviously, we wouldn’t have been able to intervene before.

And in general, speaking of, you know, water breaking, we will check the amniotic fluid level when we’re doing the check with the heartbeat. Again, we have an ultrasound, so just making sure the amniotic fluid level is, you know, within normal limits, that it’s not getting excessively low. It doesn’t often happen after 36 weeks. Most people get to their due date, and their amniotic fluid is normal, but it is a little more likely to happen after that point.

Dr. Nathan Fox: Yeah, I mean at 36 weeks, it’s almost…it’s sort of like the beginning of pregnancy, where the beginning of pregnancy is kind of a new experience, right, for people. Like they weren’t pregnant, and now they are, and so there’s a lot of stuff that happens, and there’s a lot of questions about it, and a lot of talk about it. So like we said at the beginning, we get to know them, they get to know us, they have questions, we have questions, and then when you get to 36 weeks, the same thing is happening in preparation of labor, right? Because labor is going to be new either for this person entirely, or for this pregnancy.

And so there’s, again, a lot of things we have to look for to prepare for labor. Like you said, what’s the position of the baby, what’s the fluid…? There’s things we have to just check in general about the health of the mother, the health of the baby, the preeclampsia, the size of the baby, all these things, and also the questions, right? Questions that we may have for them, like do you have this set up? Are you ready? Have you thought about this…? And they have for us, you know, what’s it going to be like? When should I call, you know? And that really ticks up in terms of volume. And so, having weekly visits is not only I would say important medically, but just logistically, because a lot of stuff happens. People have questions, they have new questions, this is the time, frequently, if, you know, their partner has not been coming to all the prenatal visits, this is a good time for them to start coming, you know, because they may have questions as well. And so, I think that the weekly makes sense both medically, but also just logistically. I mean there’s so much…

I mean, again, sometimes people come in and they’re like, yeah, nothing much since last week, we’re good, and it’s a quick visit, and they go home, and sometimes it’s like, we’re going over the whole birth plan at 37 weeks, so it can be a very long visit. And so, you know, on average, they’re probably short visits, but some are very short, and some are long, and yeah, and we basically do that weekly. The only other test that we do around that time is a Group B strep culture. It’s a vaginal culture to check for this bug, Group B strep. That’s done routinely around 36-ish weeks. After that, there’s really no testing, unless we have to do a formal ultrasound or non-stress test. Again, that’s based on risk factors, or if you go past your due date. And that’s it, that’s your prenatal care. We just keep doing weekly, or maybe really past the due date, sometimes twice weekly, if someone needs it. And then they’re no longer prenatal. Then they’re in labor…until that happens.

Excellent. So, I think this is a really good review, these past two weeks, of sort of what to expect. And again, for everyone it might be a little different based on, again, who’s taking care of you, where you are, what medical issues you have, what happened last pregnancy. And again, sort of the high-level points, there’s no perfect way to do this, this is just sort of maybe a framework for what to expect. And really, most of prenatal care is conversation. It’s not the testing. Again, there’s a bunch of blood tests at the beginning, a little bit in the middle, a few ultrasounds, but it’s really conversation. And if you’re having a lot of communication with your doctor or with your midwife, it means you’re probably having good prenatal care. If you’ve never had a chance to speak to someone, and you’ve never been asked a question, then that’s probably…you may want to look elsewhere.

Again, if you go somewhere and all you do is have blood tests and ultrasound, but no one’s ever speaking to you, and you’re never speaking to anyone, I would say that’s a red flag. Whereas if you feel like there’s conversations happening, and you’re asking questions, and they’re asking questions, and there’s a lot of back and forth, then probably you’re going somewhere that’s giving you good prenatal care.

Sarah: Yeah, and I’ll also add, because you mentioned birth plan, I’ve sometimes set up even, like, a virtual visit with patients, aside from even, let’s say, like, the 36-week visit, just to go over a birth plan. Because I feel that takes time, and there’s usually a lot of questions that come from that. So sometimes, we’ll cover a lot at the 36-week visit, but sometimes once a week isn’t enough for, like, the talking portion of this, and that’s fine. So, I’ve definitely done that.

There’s also just so many questions to answer about, you know, how do I know…especially for first-time parents, how do I know I’m in labor, logistics, where do I go when I’m in labor? So explaining that as well, you know, what to expect when you’re admitted to the hospital, just all the questions about that, I give my little tips on things to bring to the hospital… And I tell everyone just write down…as soon as you walk out the door, you may have five more questions that pop into your head. Just write them all down, keep a running list on your phone. And again, if you really feel like the visits, you know, there’s just, you know, so many things that come up that you want to go over, definitely setting up a virtual visit is a good way to go over those.

Dr. Nathan Fox: Yeah, that’s actually a really good point. I’m glad you brought it up. And it would have been…I would have been remiss if we didn’t mention in the podcast, write down your questions. I mean, because in between visits, there’s always these questions that pop into your head, and I would say 90% of people think they’re going to remember, and 90% of those people don’t remember the questions, and everyone’s like, argh, what’s my question? I forgot, I had something… Whereas people who come with a list, they get their questions answered, and so that’s a really good thing. Again, if it’s urgent, you should ask in between visits. But if it’s just something like a question that you know you’re going to want answered, write it down somewhere so that when you’re sitting at the visit, you can get all the questions answered either at that visit, or the upcoming visit. That’s a good practical tip for prenatal care.

Sarah: And for myself, I’ve known myself to do that when I go to doctors, too.

Dr. Nathan Fox: Yeah, good stuff.

All right, Sarah, thank you so much. This is a great back-to-back on prenatal care. Yeah, and obviously a lot of things we discussed have their own podcast unique to them, but this was a great overview. Thanks for doing this.

Sarah: Absolutely.

Dr. Nathan Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health, and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.