“The First Prenatal Visit” – with Dr. Sara Kostant

Dr. Fox: Welcome to the “Healthful Woman” podcast, the fastest-growing podcast in women’s health. Today’s Monday, May 9th, 2022. In today’s podcast, Sara Kostant returns to talk about the first prenatal visit. We talk about the goals of this visit, when it’s done, and what actually happens during that visit. This is a really good follow-up to the podcast Sara and I did together in 2020 on the preconception visit, as well as the podcast Melka and I did together in 2021, titled, “I’m Pregnant, Now What?” This would probably be a helpful podcast for anyone considering a pregnancy, or someone who’s early long in their pregnancy, as well as anyone interested in what goes on during prenatal care. All right. Thanks for listening. Next Monday, we’ll be hearing a birth story from Hani, on VBAC after two caesareans. Meanwhile, enjoy today’s podcast. Have a great week.
Welcome to today’s episode of “Healthful Woman”, a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN 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. Dr. Kostant, Sara, welcome back to the podcast. How you doing?
Dr. Kostant: Can’t complain. Just got back from a week in, climbing mountains in Colorado, so…
Dr. Fox: Beautiful. Well, you look very well-rested, and zen, and well, and so, that is amazing. It’s nice to see you, and it’s good to have you back on the podcast. We were just discuss… You’ve had some popular podcasts, a lot of listens, and I think that this is gonna also be a pretty popular one, because it comes up a lot, obviously, in pregnancy, the first prenatal visit, that sort of big first visit, and the mystery surrounding it, like, what do we do, what happens, and what to expect? And I think this is a pretty good podcast, maybe, to follow up, first, on the one that we did about preparing for pregnancy, and then the one I did with Melka about, “I’m Pregnant, Now What?” Sort of, and then this is really the next one in that series, what’s gonna actually happen at the first visit? How do you sort of describe on a higher level what we do at the first visit? Like, what’s the goal of that visit, essentially?
Dr. Kostant: It’s really a chance for us to get to know the patient, you know, introduce ourselves, you know, tell them about our practice, what we’re like, what we do. But it’s also our chance for us to get to know them. You know, for a new patient that we’ve never seen before, like, when someone walks into my office, I don’t know anything about her, her health history, her medical…yeah, medical-surgical history, prior pregnancies. Some of our patients have seen us before for annual exams. And so, then, you know, we at least have that background. And sometimes we already have an idea of, you know, some issues that could come up in the pregnancy based on their health background, but for a patient who’s never seen us before, really just getting to know them, getting a really detailed medical history, surgical history, pregnancy history, family history, just so we know, you know, what are some possible things that could come up in the pregnancy that we need to be aware of. Also, getting to know the patient, not just, you know, from a medical standpoint, just from a personal standpoint. You know, establishing a certain comfort level, trying to, you know, gain some trust, and also to find out the patient’s expectations for our practice and for her pregnancy.
And some patients are really just there, you know, especially if, you know, maybe it’s a first pregnancy, they, you know, just wanna make sure everything is going okay, and they don’t have much more expectation than that. And some patients have, you know, very detailed ideas of, you know, questions they wanna ask, and how they, you know, what type of practice they wanna go to. And so, part of it is also just establishing that type of relationship as well.
Dr. Fox: I think it’s really interesting and telling, and also really important, that you started with that, meaning I think a lot of people are under the impression that when they come for their first prenatal visit, the first thing we’re gonna focus on is this pregnancy, right? Is it okay? What’s gonna happen? When are you due? And all these things. Where, in fact, correctly, that’s not our first goal. Our first goal is to get to know the person, and vice versa. Like, we should know her, she should know us, and developing an understanding of one another. On our end, it’s understanding, you know, who she is from a health perspective, from a personality perspective, from a social perspective. Again, like you said, to develop that relationship, develop some trust, and the same way, we want her to get a sense of who we are as people, who we are as a practice, because, hopefully, it’s the right fit for her, but maybe it’s not. Like, that’s okay.
You know, if we’re not the right fit for you, then you should be somewhere else, and that’s great. You know, everyone should find who they’re comfortable with. And we really try to focus a lot on that. And I think it’s after that happens, then we start focusing on the pregnancy itself. And so, we obviously do that in the first prenatal visit, but it’s not the highest-level goal we have, because there’s gonna be many visits, obviously, to do that. But at the beginning, it’s really important someone coming in has that level of confidence, and security, and comfort with where they’re going, because this is gonna be a relationship that’s gonna last close to a year at minimum, right? And maybe many, many years. And that’s an important part of it. And, what are the things that you might, you know, do to sort of develop that? Do you just start off by saying who you are, or is it more asking questions, or how do you sort of go into that with somebody, to develop that relationship?
Dr. Kostant: One of the things I like to do at the first visit is just start with a simple question, which is “How are you feeling?” Because the first prenatal visit, often, and as we’ll talk about, unless someone’s transferring to our practice later in the pregnancy, most patients come to us some time between 6 weeks or 10 weeks after their last period, or, you know, if they went through IVF, they’ll have a specific embryo transfer date, but it’s a time when many women are not feeling well, to be honest. They may be very nauseous, very fatigued. Some patients are used to that if they’ve had a pregnancy before, but for some patients, even if you know that’s technically supposed to happen, you’ve had pregnant friends, you know that you’re supposed to be really nauseous, once it actually happens to you, it’s rough.
And I think one way that I try to kind of, like, establish a rapport is just, you know, besides just saying, “Oh, great, you know, pregnancy,” I just like to say, you know, again, “How are you feeling, physically?” And I think that helps kind of establish a connection. And I also say, “You can be honest. Like, if you’re feeling terrible, let me know.” And I think it’s also good from an emotional standpoint, because I think that there are always patients that are very, you know, maybe it’s a very planned pregnancy. They’ve been trying to get pregnant for years, and they’re very excited about it. And sometimes it’s not planned, but they’re still excited about it, and sometimes patients are just having mixed feelings. And I think it’s good to kind of just tell patients, “Yeah, you know, you can be upfront with me with how you’re, you know, feeling about the pregnancy.” Or also just like, you know, “What are you thinking right now?” Because I think that way, I can get an idea of, you know, where someone is both emotionally and physically. You know, if someone’s really not feeling well physically, I’ll jump into that, kind of talking about, “Okay, here are some things that we can do.” Same thing, you know, emotionally also.
Dr. Fox: Yeah. I also try to start very open-ended, to see where she wants to go with the first visit. And it’s different for a lot of people. And I think that it’s also…it’s generally a good sign when the doctor’s comfortable listening, and not just talking, because if someone sits down and I just start talking and telling them all the things they need to do, I mean, I could send them a recording. I could send them a podcast. You know, it’s more so about us hearing them and what their concerns are, what their, you know, physical complaints are, you know, psychosocial, you know, mental health, like, all of those things come up if you just sort of ask people questions and they feel that they can answer honestly and openly. And once we’ve developed that relationship, we sort of then go into, you know, the pregnancy itself, like, you know, the viability of this pregnancy, is it healthy? How far along are you? Those types of details, and then sort of her general health, and sort of the plan for the pregnancy. And we’ll get into sort of that in a more detailed fashion. One thing that people ask a lot is when should they come in for their first visit? When should they first be seen?
Dr. Kostant: In general, 6 to 10 weeks after the last period…it’s a very general time. I will say, though, for patients that have had a prior, and we’ll talk about this a little bit more, like, a prior tubal, or ectopic pregnancy, and then this is their next pregnancy, for patients that are having any bleeding, like, they’ve missed a period, they know they’re pregnant, they took a home pregnancy test, but they’ve started bleeding, I would want them to come in earlier, just because that’s a little bit of an exception. We would wanna do an ultrasound earlier, make sure everything’s okay. But for patients who, overall, they missed their period, they have a positive pregnancy test, but otherwise, you know, they’re feeling okay, I think 6 to 10 weeks is reasonable.
I’ve had some patients sometimes come in a little earlier. It’s not a bad thing. The only downside is sometimes before six weeks, we can’t see a fetus yet on the ultrasound. It could be everything’s totally fine. We will usually at least be able to tell that the pregnancy’s in the uterus, which is, again, can be very important, depending on someone’s history. So, I tell patients if they end up coming in, like, a little before six weeks, which sometimes happens if they’re really nauseous, and just need to be seen just to address that, I’ll say don’t worry if we don’t see anything definitive on ultrasound. We’re gonna have you come back in a week or two. So, that’s the only downside, honestly, to coming in a little earlier. You just don’t get that reassurance of, “Oh, there’s the, you know, fetus with a heartbeat that you can see usually after six weeks.”
Dr. Fox: Yeah. I mean, sometimes, logistically, it’s not even that possible because, you know, we do our dating, again, six weeks means six weeks from the period, which would be about four weeks from conception and about two weeks from missing your period and getting a positive home pregnancy test, meaning if someone has a positive pregnancy test and they call the office and they wanna be seen, all right, if there happens to be availability and they’re seen within a week, I mean, we don’t usually try to do that, like you said, just because there’s not that much that’s gonna happen at that visit. But if someone needs to be seen, obviously, that’s okay. Yeah. I agree with the 6 to 10. And I think that leeway there is a good thing, meaning I know that there’s some practices that insist that the patients wait till they’re 10 weeks pregnant.
I don’t really know why. I guess that’s… I mean, maybe because if they’re gonna miscarry, they want it to be before they see them, but that seems a little warped, you know? It would seem to me that the opposite, but I really don’t understand that so much. We give people leeway because scheduling, they may wanna see a specific doctor, or come on a specific day, or they’re out of town, or they’d rather come earlier or they’d rather come later. So, we give them that leeway. And there are some people who we prefer come on the early side, like you said, people, you know, either significant symptoms or certain history and they would know about it, but otherwise, we sort of leave it up to them when they wanna come. And if they, first visit’s at 10 weeks, then, okay, the next visit might be at 12, and their first visit’s at 6 or 7, we might see them again, you know, in another couple of weeks. We leave it open, just so people have some agency over when they come in for their first visit. Some people don’t wanna be seen early. They wanna wait. They’re like, they’re busy, and they just wanna, you know, wait and come in in a month. And that’s fine. They come in for the visit, right? What actually happens during that visit? You said you start talking to them. Okay. So, you’re talking to them, and what else that gets done?
Dr. Kostant: I’ll go through their entire medical history, surgical history, allergy history. Go over, you know, if they’ve had any pregnancies, go over their prior pregnancies. If they haven’t, I’ll just go over their… And a lot of times I have this information before, their path to getting pregnant. Was this a spontaneous pregnancy? Was it an IVF pregnancy? And so, I’ll basically start with that. Many of our patients, when they come to see us for the first visit, usually will have an ultrasound, at least in our practice, will often have had an ultrasound prior to their visit, to measure the fetus, confirm the dating, or establish the dating. So, a lot of times, I’ll already have that information. If some of our patients don’t have that scheduled and then I do the ultrasound, and I usually will do that after I’ve gone through the initial history, but depending on their symptoms or history, I may decide to do that first.
So, just as an example, I’ve had, you know, we’ve had a few patients who this is their first pregnancy after a pregnancy loss, and they’re coming in very anxious. And so, I’ll try to do the ultrasound sometimes. I’ll introduce myself and say hello and ask, you know, “How are you feeling?” But I’ll say, you know, “I can go ahead right now and do the ultrasound.” Let’s say it’s been seven, eight weeks since your last period. Maybe they haven’t had an ultrasound in the pregnancy, just so they can at least get some, you know, potential reassurance, and then I’ll bring them to the office and go through, you know, the entire history. So, sometimes I’ll do things a little bit out of order. If someone otherwise is feeling well and it’s their first pregnancy, I’ll go through their entire history first, look for anything that could potentially, you know, any health issues that could potentially be an issue with the pregnancy, just to kind of make a mental note to go over later, and then I’ll go ahead and do the ultrasound. Usually, well, when I do the ultrasound, many times it’s a transvaginal ultrasound if the patient is coming to us early. And so, often, with that, I’ll do a general physical exam as well.
Dr. Fox: I wanna start actually with the history portion. It’s really important because when we’re taking a history, you know, there’s sort of what I think about as, like, three parts of the history. There is the history of this particular pregnancy. Like you said, how did they get pregnant? When did they get pregnant? And that’s important to us because we have to sort of figure out how far pregnant do we expect her to be based on her periods, based on when her last period was, and all of that, you know, based on when her pregnancy test was, and we compare that to the ultrasound findings, and it helps us sort of verify that this is “a normal pregnancy,” or “a viable pregnancy.” The second thing is her prior pregnancies, because what happens in those pregnancies is really relevant for what we might do in this pregnancy, right? Was her prior pregnancy a C-section? Did she have high blood pressure? Did she have diabetes? Did she have a preterm birth? Is this her first pregnancy? Did she have miscarriages before? Like, all those things sort of play into what we’re doing this pregnancy.
And then, like you said, her general health. Many of our patients, like you said, do come to us for gynecology visits, and we sort of know their health, but many don’t, and we need to know, like, do they have Crohn’s disease? Are they on medication? Do they have allergies to certain things? You know, have they been hospitalized? Have they had surgery? Have they had blood transfusions? Like, these are things that we need to know, again, for this pregnancy. And sometimes we’re asking about things and people are like, “why are you asking me, like, about my sister’s health or about my family health?” And it’s all relevant. I mean, you know, family history, and genetics, and even social history, I always ask people, what kind of work do they do? You know, where do they live? And it’s not… I mean, it is nice, you know, we’re being social and to know them, but that’s important, you know, what kind of, you know, what they do every day. Do they exercise? Do they smoke? I mean, these are really important things that we get into in the history.
The examination, the physical examination, I mean, most people come in, are healthy and young. And we’re not really gonna pick much up, but it’s important. We always, you know, we do a breast exam, you know, we do a pap smear if they’re due for one. We do an exam. And it is important, although, usually, it’s just normal. The ultrasound, for whatever reason, is an area of controversy. I don’t get it. Sort of like the first prenatal visit, we do it routinely at the first visit. And there’s a lot of places around the country that don’t. I don’t really get why. I guess maybe it’s an issue of availability, or resources, but it makes no sense to me. I mean, if you have the option to get an ultrasound early in pregnancy, that information is certainly gonna yield more than an exam will, right? Because you’re gonna find out, is she having singletons or twins? You’re gonna find out, is there a heartbeat? Is this a viable pregnancy? Is it matching up size-wise so we can pick a due date?
And also, if it’s not a viable pregnancy or it’s an ectopic pregnancy, that’s really bad news, but you definitely would rather know about it in advance than just show up in the emergency room two weeks later, bleeding or having a complication from an ectopic pregnancy. So, we do it routinely in the first trimester. I’ve never met someone who convinced me not to do it at the first visit. It just makes no sense to me. Again, unless there isn’t an ultrasound available and you can’t get one, okay, but nowadays, most OB-GYNs have them in their office. It should be pretty straightforward. Occasionally, patients ask me, like, “Why are you doing this ultrasound?” They feel like there’s something, like, wrong with it, like it’s somehow…I don’t know if it gets some bad press out there somewhere for “too many ultrasounds.” But this is a really important one.
Dr. Kostant: Yeah. I think this one, and, you know, later, the detailed anatomy ultrasound, I would say, like, these are kind of like the two that are the most important. I think this just saves, like you mentioned, for all the reasons of, you know, diagnosing, making sure the pregnancy is, you know, at least continuing in the uterus, but also, we’ve had many patients who, you know, we talk about dating based on your last period. Sometimes they’ll say, “I get my period three times a year, and I started feeling… I wanted to get pregnant, but my last period was three months ago, and I started feeling unwell and took a pregnancy test.” But based on their history, I don’t know if they are, you know, 10 weeks pregnant, 8 weeks pregnant. I’ve literally had patients sometimes get their period, like, once or twice a year, depending on their, you know, health history. And that’s a whole other discussion, but you can’t always use the last period reliably to determine the dating of the pregnancy.
I think when I was in residency, we did have one ultrasound in our resident clinic, maybe, like, 13, 14 years ago. So, it was available if we needed to, you know, look, but we did not have a transvaginal probe, I think, on that ultrasound. We just had an abdominal probe. And so, really, earlier than 10 weeks, or at least earlier than 9 weeks, it’s sometimes hard to see a heartbeat. We would just use the small, like, doptone, that we would just put on the belly to hear the heartbeat. Typically, many of our patients did not… We didn’t actually take a look at the fetus until maybe 10 weeks or even later, because they would usually, again, for a longer discussion, but they would maybe get an ultrasound around 12 or 13 weeks if they did the nuchal translucency. But because of that, we sometimes had, you know, I think there were some dating issues with some pregnancies, because they would get the detailed anatomy ultrasound later, and it would be kind of off, and it was like, “Well, were they really, you know, when we first saw them for the visits, were they really that far along?” So, I think it saves a lot of trouble later with figuring that out.
Dr. Fox: Yeah. I mean, the principle is that the early ultrasounds are the most accurate in establishing how far along the pregnancy is, meaning we sort of…the default is we go by their last period, and then we do an ultrasound, and if the ultrasound is sort of in line with that, we stick with the last period date. And if the ultrasound’s way off, we switch the due date. But that’s really only reliable early in pregnancy. So, if someone comes in and their first ultrasound is later in pregnancy, and they come, and they’re 20 weeks, and the baby’s measuring 18 weeks, that either means the baby’s horribly growth-restricted, and it’s a big problem that the baby’s two weeks behind, or, no, she’s just two weeks less pregnant, and we have the due date wrong. And those two are wildly different in terms of the prognosis. The first one, the prognosis is very bad, and the second one’s totally fine.
Dr. Kostant: Right.
Dr. Fox: And so, that’s one situation where it’s really relevant to know the dating. Others, a lot of people have undiagnosed twins. If they don’t get an early ultrasound, they don’t found that they have twins until the middle of pregnancy, and that’s…can cause some problems. And again, it’s just, we all know as residents a time, you know, if you’re in the emergency room at night and someone shows up with an ectopic pregnancy, you know, hemorrhaging in her belly, and that would’ve been diagnosed if she had an early ultrasound. Or she’s miscarrying in the middle of the night, and bleeding really heavy, and distraught, and she doesn’t know how far pregnant she is because never had an ultrasound. And so, that’s why we do it. And I think that most people have the availability, they’re gonna do it routinely, at the first visit. So, you get the full history, you’ve got to know her, you’ve done the exam, you’ve done the ultrasound, everything’s going okay with this pregnancy. What are the things that you wanna cover when you’re talking to her at the first visit, after you’ve done all the assessments?
Dr. Kostant: There’s so many things. And I’ve even had situations where I’ve told patients, “We’re gonna cover, you know, a few things today, but we’re gonna save some things for the next visit. Still, all things important for the first trimester, but we can’t do it all in one day.” So, I always tell patients that, you know, “We may not cover everything now, but don’t worry.” Because I do wanna leave time for them to ask their questions. One of the things I go over is just, what are the next several weeks going to look like? Like how often are you going to be seen? If everything looks like it’s going well with that visit, what to expect as far as how they’re going to feel, you know, how to get in touch with us if they have any concerns.
A lot of going over what the next few weeks looks like, and their upcoming visits, will also depend on what type of genetic screening they wanna do. And that’s, again, a whole topic in and of itself. And as we were just discussing before this, we have a few podcast episodes just on that. But it’s important to at least initiate the discussion, because if patients do want to do some type of genetic screening, we’ll probably want them to be back around 9 to 10 weeks, which, frankly, even if someone doesn’t wanna do screening, it’s not a bad idea anyway, just to check in. But, specifically, if someone does, because there is some blood work that we’re gonna wanna do, and then we’ll likely have them come back at 12 to 13 weeks as well. And so, that’s why I bring it up, just to kind of say, “Look, this is something that’s kind of a more extensive discussion.” You know, I’ll introduce the options, just get an idea of where they are.
And then, you know, many of our patients lean toward doing what we call non-invasive blood test screening. Some patients actually wanna learn more about diagnostic testing, or CVS. And we have some patients that have no interest in doing any genetic screening at all. And, in fact, will sometimes request, you know, “Can I not come back at, you know, 10 weeks? Can I just come back at maybe 12 or 13 weeks? Because I’m feeling well and I’ll call if there’s an issue.” But they’re not gonna do any of that screening. And I’ll say, “Sure.” So, that’s one thing that I’ll kind of go over, is where are they leaning? And if they haven’t even begun to think about that, I’ll just introduce the topic, I’ll give them some basic information, and I’ll tell them, you know, “Let’s have you come back around 10 weeks. We’ll do another ultrasound, make sure everything’s okay, and we can, you know, talk about it more and make, like, a more final decision then.”
Dr. Fox: Yeah. I think that that’s important. I generally think of it that the beginning of pregnancy, the visits are more frequent. You know, there’s their first visit, whenever that might be. And if it’s any time before around 10 weeks, usually their next visit’s around 10 weeks. So, if they come in at 6, usually the next one’s around 10. If they come in at 7, it’s usually the next one around 10. And then, after 10 weeks. they come again at 12 weeks. There are people who come more frequently than that, either people, let’s say, with a history of miscarriages, who are very concerned, or, like you said, they’re bleeding or they’re ill. And so, we may see them every week in the first trimester if needed. Once they get to 12 weeks or so, and everything’s okay, I tell them, “Usually by that point it’s gonna become less frequent.” I would say the standard is about once a month for a while, until the end of the pregnancy, when it gets frequent again.
So, I actually set them up saying, “All right. At the beginning of pregnancy, we’ll see you every week or two, give or take, until around 12 weeks, and then it gets less frequent.” Again, unless they needed to be seen for some other reason. And I think that’s an important expectation. Some people are really happy to come a lot, and some people are really unhappy to come a lot. And so, there is definitely discussion with people about if they wanna come more often than we think or less often than we think. And, again, we’re very flexible at this, unless they’re gonna be missing some tests that they want, in which case, we’ll just let them know, “Hey, if you missed this visit, you may not have this test in time” or whatever it is. What about in terms of instructions that you’re definitely gonna wanna cover with them, whether they ask about it or not?
Dr. Kostant: There are a few precautions in early pregnancy, and you actually wrote a good article that we give to patients about “The Dos And Don’ts in Pregnancy.” I usually like to go over them, one, because there’s actually a lot of misconception around that area. And sometimes I’ll have patients saying, “I heard I can’t do this, this, and this.” And I’ll say, “Oh. No, that’s fine.” Like, you know, “I can’t eat pineapple.” And you can eat pineapple, by the way, whoever’s listening to this. It’s okay to eat pineapple.
Dr. Fox: I never even heard that you couldn’t eat pineapple. I know you can, but that’s a misconception?
Dr. Kostant: I had to look into this…
Dr. Fox: Yeah.
Dr. Kostant: …but there’s some thought that there’s a chemical in pineapple that is a cervical ripening agent, can have a cervical ripening effect.
Dr. Fox: If only.
Dr. Kostant: I know. I said that we should give it to everyone who wants to go into labor. But, no, it does not increase the risk of pregnancy loss or preterm labor. But I do go over a few things. If a patient, you know, is a smoker, you know, I’ll talk about smoking cessation. If a patient is… Most patients, by then, if they’re, you know, social alcohol users, have stopped using alcohol, but that’s one thing I’ll look into, is just daily habits. Is there any type of actual, like, dependence or addiction? But then I also go over a lot of routine things, like, you know, for foods, I’ll go over just general food safety.
And, again, this could be, you know, like, a whole topic in and of itself. But, you know, the main things I talk to patients about are, you know, I say not having unpasteurized cheese. I’ll say… And you can tell me if you disagree with any of these. You know, just making sure if they’re having meat at this point, like red meat, that it’s… The professional eater in me hates to say this, but to have it more well done. I’m personally, you know, I tell patients, “It’s okay if you eat sushi, as long as you eat it from a place where it’s literally prepared right then and there.”
Dr. Fox: Right.
Dr. Kostant: I go over things that many people are aware of, but, you know, a lot of times, I’m actually letting them know that there are things that are okay to do. I’ll talk about exercise, and, again, if they’re feeling well, I’ll encourage it. We’ll talk about, you know, sexual activity as well. And I’ll say, again, unless there’s a particular concern, you know, let’s say bleeding or something like that, that’s also okay. And these are all things that, you know, patients tend to ask, like, “Is it okay if I do this?” You know, or, “I heard this. Can I… You know, is this true?” I think those are… And, you know, general over-the-counter medications is also a big thing I go over, because putting aside, you know, the whole topic of nausea and how to treat nausea, but, you know, sometimes patients will have allergies, or a cold, or, you know, especially during the time of COVID, and hopefully, patients didn’t get COVID, but if they did, you know, what are things that they could take if they weren’t feeling well? So, I’d make sure to kind of lay that out, just so that when they leave the office, they kind of feel like, a little more empowered. It’s like, “Okay. Yeah. You know, if I have a headache, I can lie down and take some Tylenol,” and that’s okay.
Dr. Fox: Yeah. I think that one of the hard things about the first prenatal visit is there’s so much that can be covered, and there’s so much that is, by some people, expected to be covered. And it’s really too much, right, for an hour, because we’re supposed to… You know, it’s important to go over all the dos and don’ts about nutrition, about genetic screening, about vaccines, about health, about travel, about COVID. I mean, about mental health. I mean, there’s all these things that are all really important. And you could spend 15, 20 minutes on all those topics. And so, now you’re talking about a three-hour to four-hour visit, and that’s just…no one wants that, right? Patients don’t wanna sit there for four hours. It’s not practical. And so, it’s hard. We try to touch on all of them and sort of see what are the areas that either she’s most curious about or needs to know about.
And I think one of the really important parts of the first visit, both from us on the doctor’s side, but also for anyone on sort of the patient side, is not just all the information you’re gonna get or give in that hour, but, “What do I do for more information?” Right? “When I have a question, what do I do?” And that might be, okay. Here’s how you contact us. Is it by phone? Is it by email? Is it by the, you know, EMR that we have, there’s a way to, you know, message us, or what are the resources that we think are really good to read? Like, what is a good book to read? What’s not a good book? What are good websites? What do we have on our website? And that’s part of the reason we sort of hand out an article on the dos and don’ts. It’s part of the reason we put a ton of stuff on our website. It’s part of the reason that we have this podcast.
And I tell people, like, “You’re gonna have a lot of questions. You know, go to these resources. Like, they’re there for you. And these are the ones that we trust and we like, or we made ourselves.” And that’s really important, because, again, you could spend an hour talking about genetic screening. I sometimes spend an hour talking about genetic screening with people, but if you did that, there’s no more prenatal visit, because it’s only an hour. And so, sometimes it’s safe for a future visit. Sometimes it’s a phone call in between visits. Sometimes it’s a phone call to one of our nurses, but, you know, we should be telling people where they can go for more information, and people coming to a prenatal visit with their provider should ask, “What are the things that you like? Like, what are the books that I should read or what are the websites I should go to?” so everyone’s on the same page, because there’s so much you can go to. And if you just Google it, it’ll lead to bad places, usually.
Dr. Kostant: Like the pineapple.
Dr. Fox: Yeah. The pineapple website. Yeah. I mean, it’s a really important point. And again, this is, like, literally why we did this podcast. So women could have, you know, an hour on one of these topics as opposed to, you know, two minutes with one of the doctors, which may be all that’s allotted for that, unfortunately.
Dr. Kostant: My goal is to get people comfortable, at least till the next visit. Like, let’s cover, like, what you really need to know for the next couple of weeks. And I’ll tell patients, “We are gonna cover certain things, like, much more at the next visit and even the visit after.”
Dr. Fox: Right. Yeah. The first visit’s generally not a great time to talk about the epidural, you know, or about the birth plan, or about nursing. I mean, unless they’re curious about your philosophy on these things, like your attitude, then it is important, but sort of the nuts and bolts, not so much. Like, that’s something that could be done later. Now, there are also some, typically, some blood tests we send on a first visit. Most of them are just really routine stuff that everybody sends. You send an HIV test, you send a blood count, you send their blood type, you know, certain check of your immune to certain viruses. You know, if you’ve been vaccinated, you got infected with them, sort of routine stuff.
And then, like you said, if it’s time for the genetic testing, and they’re gonna be doing it, then we’ll send it either at the first visit or the second visit, based on the gestational age. But there aren’t a lot of remarkable blood tests we send at the beginning, unless they have specific health issues or prior pregnancy outcomes. Most of the bloodwork is just a routine panel. And, honestly, we send a lot of it just because you kind of need it when you come in to deliver. They wanna know a lot of these things. I mean, yes, occasionally, they’ll pick up something that’s relevant, but almost always, they’re just normal, in terms of the blood work. And then what about prescriptions? What are we sort of medication-wise or supplement-wise recommend for people at the first visit?
Dr. Kostant: So, I’ll ask patients if they are already taking a prenatal vitamin with folic acid. Many people are. Not everyone has started one yet. Some patients want to, but they’re just quite nauseous. In that case, what I’ll often do is recommend they just take folic acid, which is really probably the most important thing to have, especially in the early first trimester. And ideally, you know, patients, if they’re planning a pregnancy, should be on it, but if they hadn’t started it or if it’s unplanned, and they’re, you know, six weeks pregnant, I’ll tell them to start it as soon as possible, at least 400 micrograms of folic acid, just alone, because that’s usually a little easier to tolerate if you’re nauseous than an entire prenatal vitamin.
Dr. Fox: Yeah. It’s a very small pill, the folic acid. The prenatal can be like taking a golf ball, but the folic acid’s really tiny, so usually, people can tolerate it.
Dr. Kostant: I’ll make sure patients are at least taking that. If someone can tolerate a prenatal, or they’re getting to the end of the first trimester, if that’s when I’m seeing them, and they’re not as nauseous, I’ll recommend the prenatal with DHA as well, which are kind of like a healthy, like, fatty acid that can help with brain development. The other supplement that we’ve actually started really recommending for all of our patients, at least to start by about 10 weeks, again, you know, as long as they’re able to tolerate it and don’t have any allergy to this, is actually a low-dose aspirin supplement.
We used to recommend it for patients that were kind of what we would call, like, a higher-risk category for preeclampsia. Patients that were over 35, patients with twins, IVF pregnancies. But we began recommending it for everyone, because it’s a very low-risk intervention, and really, everyone is potentially at risk for preeclampsia. Definitely, some patients are much more risk than others, but because it’s such a simple intervention, and could have such a significant effect, and most patients can take it without any difficulty, we started recommending it across the board for everyone, even patients that are “low-risk pregnancies.” Again, if someone’s extremely nauseous, I’ll tell them to hold off, but if they’re feeling well, it’s a pretty small pill. I’ll recommend that they, you know, try taking it at least by about, you know, 9 or 10 weeks. So, that’s another thing that I recommend.
The last thing is calcium supplementation as well, which I think is actually important for a couple reasons. One is… And just as I was talking about with aspirin, it may help reduce the risk of preeclampsia later in the pregnancy. And we usually recommend a total, from diet and supplementation, about 1,500 milligrams a day. But I think, especially during childbearing years, is, you know, especially for patients that may be breastfeeding for a while, and have pregnancies maybe a couple years apart, the calcium is just really good for general bone health as well. You know, I’ve told patients that, you know, take it during the pregnancy, and it’s probably not a bad idea to continue it after the pregnancy as well.
Dr. Fox: Yeah. I mean, the recommended amount of calcium for everybody, non-pregnant women, pregnant women, is 1,000 milligrams a day. And very few people get that in their diet. I mean, a glass of milk is, ballpark, 300. So, if someone has three servings of dairy a day, fine, they’ll get there. But most people don’t. And the prenatal doesn’t have that much, because it takes up too much room. And so, usually, you have to take it as a separate supplement, whether, it could be something you swallow, a chewable, they make it as gummies. So, yeah, usually, it’s something that’ll have to be supplemented, unless, again, if someone’s a big dairy-eater, then, fine, they don’t need it. That’s okay. But most people, at least that I see, aren’t.
So, you’ve seen them, you had the, you know, sort of developed a relationship with them, got their history, the exam, the ultrasound, the bloodwork, the prenatal or the folic acid, the calcium, the baby aspirin, and you have their next visit set up. And a lot of the things that you talked about are the things that people ask about, obviously, but we always give people an opportunity to ask whatever questions they have, because sometimes they’re sort of the “standard ones,” but a lot of people have unique circumstances, or specific concerns, or specific questions related to, “Oh, you know, my job requires me to travel there.” Or, “I do this, you know, exercise. Is that okay?” And so, it is really important to leave time for questions. And usually, it works, in terms of timing. Sometimes we go over, sometimes we finish early. How long do you try to leave for the question, answer session?
Dr. Kostant: I try to leave, if possible, like, at least, like, 10 minutes, because I feel like you can actually cover a lot. And a lot of the questions are pretty… Like, I find that, as you mentioned, a lot of them are about certain, like, you know, “Can I do this?” Or certain exposure, like, you know, sometimes patients will actually bring other supplements they’re on and, you know? But they’re things that can be answered pretty quickly. I always tell patients, like, you know, “You will have more opportunity to ask questions.” And if there are things that really, we can’t wait till the next visit, I will sometimes set up, like, a virtual visit, just to finish up, because sometimes there are actually some significant things that are more unique to that patient that we need to go over, that probably can’t wait to the next visit.
But, you know, sometimes I have more time. Like, sometimes, you know, the history is pretty quick. You know, the ultrasound’s pretty quick. That’s all fine, and nothing comes up, and then we can spend the rest of the time going over more. So, I try to leave about 10 minutes. I also find sometimes that the questions sometimes just get woven into the visit. Like, there’s not, like, this Q&A session at the end. It’s kind of, as we’re going through things, sometimes patients will ask the questions, so it’s often, sometimes by the end, we’re kind of at the end of the hour, but a lot of the questions have just been answered. And then, I’ll take, like, a little more time, but I’ll say, you know, “If there’s a few more things that can’t wait till next visit, we will set up another time.” Because I do want people to leave not feeling, like, lost.
Dr. Fox: Yeah. I mean, and, again, we actually didn’t mention this, but in our practice, we allot an hour…
Dr. Kostant: Yeah.
Dr. Fox: …for a new pregnancy visit. Which is actually long. A lot of practices, it’s only, like, 30 or 40 minutes. Honestly, I don’t know how people can figure that out. Maybe just because we… I don’t know. Maybe we talk more. Or maybe we see people with more complicated histories, I’m not sure. But an hour’s a lot of time, and it tends to be enough for most people. And if it’s not, like you said, okay, we’ll figure out a time, either right now, if, you know, there’s no one waiting to see me, or we’ll schedule a time in the near future, just to wrap it up.
Sara, thank you so much. What a really good summary of the first prenatal visit. So, for those of you who are embarking on your first prenatal visit, with us or with someone else, this is hopefully a good outline of what to expect. And, yeah. Good luck to everyone.
Dr. Kostant: Yeah. Thanks so much. Can’t wait to meet you.
Dr. 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 H-E-A-L-T-H-F-U-L-W-O-M-A-N.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. Paid sponsors of the podcast are not involved in the creation of the podcast or any of the content. Support for our sponsors should not be interpreted as medical advice from the podcast, the host, or the guest.