Initial prenatal visit

Once your pregnancy has been confirmed, the prenatal period officially begins. Prenatal care involves a series of regular examinations and tests by a physician or midwife. In an uncomplicated pregnancy, most women will see their practitioner once a month until the 32^nd week of pregnancy. At this point, you will be seen every two weeks and in the final month of pregnancy (37 weeks until delivery) your visits will be increased to weekly.

The prenatal period not only gives the expectant mom time to get ready for the baby's arrival, but it is also an opportunity for the expectant parents to get to know the person or persons who will be directly involved in your care during labor and delivery. The initial prenatal visit is often the longest. During this first visit, a complete physical examination, along with a detailed family history and blood and lab work will be performed. The physician or midwife will calculate your baby's due date and that date will serve as a reference point in future visits when the baby's growth is assessed.

During the first prenatal visit the physical examination involves an overall assessment of the mother. This includes an assessment of the heart, lungs, and thyroid function, along with an examination to rule out any other infection. Next, the practitioner will perform an obstetrical exam, which includes a look at the mother's abdomen and measurement of the height of the uterus, along with an internal or pelvic exam.

All prenatal visits include a measurement of the mother's weight, recording of the mother's blood pressure and urine testing. A series of blood tests are also performed during the initial prenatal visit. The blood and laboratory tests that are most often recommended during the first visit include:

Hemoglobin- This test checks the mother's blood to determine if she is anemic. Women usually become slightly anemic as the pregnancy progresses, but very low levels will need to be treated.

Blood type and RH with antibody screening - This test determines the mother's blood and RH type and antibody factor. If the mother's blood type is RH negative and her partner's is RH positive, special monitoring of the fetus is necessary to check for RH incompatibility.

Rubella titer- This test checks the level of antibodies to the German measles virus that are present in your blood. If a woman becomes infected with German Measles (Rubella) during her pregnancy there are known risks to the developing fetus.

Syphilis screen- This test checks for the presence of syphilis infection. If present, treatment can be initiated so that the fetus is not harmed.

Hepatitis B screen- This test checks for infection with the Hepatitis B virus, which can be passed to an unborn child. If present, the mother can be treated during the prenatal period and the baby at birth.

HIV screen -This tests checks for the AIDS virus. If a woman is found to have HIV infection she can be treated during pregnancy, which will reduce the chances of her passing the virus to her unborn child.

PAP smear- This test checks for abnormal cervical cells, which could indicate cervical cancer.

Gonorrhea and Chlamydia cultures- Both of these infections, if present in the mother, must be treated to prevent infection of the baby at birth.

Urinalysis- This test examines the urine for the presence of bacteria, sugar or protein. It is usually performed at each prenatal visit.

Subsequent prenatal visits are usually shorter than the initial visit. During each visit the mother's weight will be recorded. Current expectations are that the mother will gain about 10-12 pounds in the first half of pregnancy and another 15-17 pounds during the second half. Experts believe that a sensible and safe weight gain during pregnancy is 25-35 pounds.

A blood pressure measurement is also recorded at each visit. Sudden rises in blood pressure can indicate complications during pregnancy.

Urine testing is performed at all prenatal visits. Specifically, the urine is checked for the presence of sugar and protein. Sugar in the urine could indicate gestational diabetes and the presence of protein could indicate toxemia, a pregnancy complication.

Your physician or midwife will measure the height of the uterus during each visit. As the baby grows, the fundus or top of the uterus begins to rise in the abdomen. By comparing the monthly or weekly measurements, your practitioner can evaluate the overall growth of the baby. Toward the later part of your pregnancy, your practitioner will check the baby's positioning by feeling around your abdomen and identifying different parts of the baby's body. As your baby's due date approaches, your practitioner may perform an internal examination to look for signs that labor is getting closer.

Each prenatal visit should also include a discussion about how the mother feels overall and whether or not she has any concerns. Your practitioner will probably ask you specific questions about symptoms such as headaches, visual problems, dizziness or swelling of the ankles, face and hands. Any of these symptoms could indicate a pregnancy complication. Additionally, your practitioner will check to be sure that you do not have any vaginal bleeding or abdominal cramping.

Somewhere between 9-12 weeks of pregnancy, the baby's heartbeat can be heard with a special device called a doppler. The fetal heart tones, once identified, are recorded at each visit.

As your pregnancy advances, the following blood and laboratory tests will most likely be recommended:

This series of blood tests is usually performed between the 16th-18th week of pregnancy. AFP is often elevated in the blood of mother's carrying a baby with a neural tube defect in which the spinal cord does not close normally. Currently, AFP is also being combined with measurements of estriol and HCG levels to screen for Down's syndrome and other chromosome abnormalities like trisomy 13 and trisomy 18. If the AFP is low, and if the other tests are low and high respectively, an increased risk of Down syndrome is present. Remember that this blood test only tells you if you are at risk for having a baby with any of these disorders. Follow-up testing is needed to confirm neural tube defects or chromosome disorders. Much controversy surrounds AFP testing, since the test can produce many false-positive results. At times, woman who are carrying normal fetuses will be unnecessarily alarmed and advised to undergo further testing based on an initial AFP screening. It is best to talk to your practitioner about your individual risks and concerns regarding AFP testing, before consenting to this blood test.

During the 24th-28th week of pregnancy a glucose tolerance test is usually performed. Following ingestion of a sugary drink, a woman's blood sugar level is measured to check for a condition of pregnancy called gestational diabetes. If gestational diabetes is present, special efforts will be necessary to maintain the mother's blood sugar at a normal level. This can often be accomplished with dietary restrictions, but may at times require the mother to take insulin. In the vast majority of cases, gestational diabetes resolves following delivery, although women who develop diabetes during pregnancy should be monitored later in life for the development of diabetes.

  Most practitioners will recommend a repeat screening to check a woman again for evidence of anemia somewhere around the 26^th-28^th week of pregnancy.

Group B streptococcus swab

 This test involves a culture of the cervix to check for the presence of strept B infection. It is usually performed toward the end of pregnancy, between the 32^nd and 36^th week. If the infection is present, the mother must be treated before labor begins, to prevent infection of the baby during the birthing process.

Medical technology has made significant advances during the last 30 years and it is now possible to detect potentially serious problems in a developing fetus prior to birth. Your practitioner will take many factors into consideration before advising you to undergo additional testing in pregnancy. Some of these considerations include: maternal age, pre-existing maternal health problems, experiences and outcomes of previous pregnancies, history of genetic or congenital disorders, presence of multiple fetuses or other high-risk conditions during pregnancy.

All decisions to undergo diagnostic testing during pregnancy should be made jointly, by both the parents and practitioner. Before consenting to any procedure, you should feel comfortable that all of your questions have been satisfactorily answered and the risk and benefit of each test has been thoroughly explained.

The most common diagnostic tests used in pregnancy include:

An ultrasound or sonogram test is often recommended at various stages throughout pregnancy. It allows the practitioner to evaluate the fetus at different stages of development. An ultrasound exam uses high-frequency sound waves to create a visual image of the fetus. Ultrasound exams are considered non-invasive and they do not involve any exposure to radiation. During the test, a special gel is applied to the woman's abdomen and a transducer is then placed on the belly so that sound waves can be conducted directly into the uterus. Often times, pictures of the developing fetus are printed and given to the parents. Sometimes the sex of the fetus can be determined during an ultrasound procedure. Many practitioners are now routinely recommending ultrasound to monitor otherwise normal pregnancies.

Amniocentesis is a procedure in which amniotic fluid is taken from the uterus using a long needle that is inserted through the abdominal wall. It is usually performed between the 16^th -18^th week of pregnancy and it is currently the most popular technique used to screen for genetic and chromosomal disorders. Amniocentesis is preceded by an ultrasound exam to determine the baby's position and the location of pockets of amniotic fluid. Once the amniotic fluid is obtained, the cells are cultured and stimulated to grow for one to two weeks. After that, the cell chromosomes can be examined and test results determined. Amniocentesis does carry a slight risk of miscarriage (about 1 in 200) so the risk/benefit ratio of the test must be considered before consenting to this procedure. Most practitioners routinely offer amniocentesis to pregnant women age 35 and older, since they have an increased risk of having a baby with Down syndrome.

CVS was developed in the 1970's as an alternative to amniocentesis to detect genetic or chromosomal abnormalities. It can be performed earlier in the pregnancy (usually between the 9^th-13^th week) than amniocentesis, thus providing earlier results. CVS involves the sampling of chorionic cells (obtained either by placing a catheter through the cervix or through the abdominal wall), that can provide a complete picture of the genetic make-up of the developing fetus. CVS does slightly increase the risk of both miscarriage and infection, so it is important to weigh the risk/benefit ratio before consenting to this procedure. Your practitioner can help you in evaluating your individual risk for genetic or chromosomal abnormalities.

During a NST the fetal heart rate is observed (by hooking the mother up to a fetal monitor) and evidence of accelerations in the heart rate that correlate with fetal movement are looked for. A reactive tracing (in which the heart rate of the fetus varies) is considered a good finding. A NST may be recommended when a woman notices a decrease in fetal movement or when the due date has passed.

The oxytocin challenge test is usually performed when results of the stress test are questionable. This test is very similar to the non stress test, except that the woman is given a small amount of medication to induce uterine contractions. The purpose of the OCT is to see how the fetus will respond to the normal stresses of labor.

This test is also used to determine fetal well-being. It involves an ultrasound examination of the fetus to determine the type of fetal movement and muscle tone that is present along with the amount of amniotic fluid

This invasive test involves the insertion of a lighted instrument through the abdomen and uterus, into the amniotic sac, where the fetus can be seen and photographed. The risk of fetal loss is estimated to be 3-5%; therefore, the test is indicated only those women who will benefit from having a fetal disorder identified and possibly treated during pregnancy.

Percutaneous umbilical cord sampling (PUBS)

This test involves the removal of blood from the umbilical cord for further study. It is performed under ultrasound guidance and makes it possible to detect several blood and skin diseases that an amniocentesis cannot.

Although the vast majority of pregnancies do not have complications, a small percentage of women do experience problems. Special testing during pregnancy can often identify problems early on, when effective treatment could resolve the problem. If your practitioner recommends any special testing in pregnancy, don't be afraid to ask questions about the test and the risk involved to both the mother and baby. The more information that you have, the better you will feel about making a decision to undergo testing during your pregnancy.

Courtesy HealthAtoZ

Eisenberg, Murkoff and Hathaway. What to Expect when You're Expecting .Workman Publishing, New York c1996.

Kitzinger, Sheila. The Complete Book of Pregnancy and Childbirth. Alfred A. Knopf, Inc., New York c 1996.

Samuels M.D. and Samuels The New Well Pregnancy Book. Simon and Shuster Inc., New York c1996.