Medical Care During Pregnancy
The Importance of Prenatal Care
Millions of American women give birth every year, and nearly a third of them will have some kind of pregnancy-related complication. Those who don't get proper prenatal care run the risk that such complications won't be detected or won't be dealt with soon enough. And that can lead to potentially serious consequences for both the mother and her baby.
That's why it's so important to start prenatal care as early as possible — ideally, before a woman even becomes pregnant.
Of course, this isn't always possible or practical. But the sooner in pregnancy good care begins, the better for the health of both moms and their babies.
Prenatal Care Before Pregnancy
Prenatal care should start before you get pregnant. If you're planning a pregnancy, see your health care provider for a complete checkup. Routine testing can make sure you're in good health and that you don't have any illnesses or other conditions that could affect your pregnancy. If you've been having any unusual symptoms, this is a good time to report them.
If you're already being treated for a chronic condition, such as diabetes, asthma, hypertension (high blood pressure), a heart problem, allergies, lupus (an inflammatory disorder that can affect several body systems), depression, or some other condition, you should talk to your doctor about how it could affect a pregnancy.
In some cases, you may need to change or stop certain medicines — especially during the first trimester (12 weeks) — to reduce risk to the fetus. Or, you may need to be even more careful about managing your condition. For example, women with diabetes must take extra care to keep their blood glucose levels under control — both before they begin trying to conceive and during pregnancy. Abnormal levels increase the risk of birth defects and other complications.
This is also a good time to talk with your health care provider any habits that could pose a risk to your baby, such as drinking alcohol or smoking. Ask about taking a prenatal vitamin that contains folic acid, calcium, and iron.
It's especially important for women who plan to become pregnant to take vitamins with folic acid because neural tube defects (problems with the development of the spine and nervous system) happen in the first 28 days of pregnancy, often before a woman even knows she's pregnant.
If you or your partner have a family history of a significant genetic disorder and think either of you may be a carrier, genetic testing may be wise. Talk this over with your health care provider, who can refer you to a genetic counselor if necessary.
If you find out that you're pregnant before you do any of this, don't worry. It's not too late to get the care that will help to protect your health and that of your baby.
Finding Medical Care
Pregnant women usually are cared for by:
- obstetricians: doctors who specialize in pregnancy and childbirth
- obstetricians/gynecologists (OB/GYNs): doctors who specialize in pregnancy and childbirth, as well as women's health care
- family practitioners: doctors who provide a range of services for patients of all ages (sometimes, this includes obstetrical care) instead of specializing in one area
- certified nurse-midwife: an advanced practice nurse specializing in women's health care needs, including prenatal care, labor and delivery, and postpartum care for pregnancies without complications
Any of these care providers is a good choice if you're healthy and there's no reason to anticipate complications with your pregnancy and delivery. However, nurse-midwives do need to have a doctor available for the delivery in case a C-section has to be done.
Your health care provider may refer you to a doctor with expertise in high-risk pregnancies if you:
- have a chronic condition like diabetes or heart problems
- have an increased risk of preterm labor
- are older than 35
- are pregnant with more than one fetus
- have another complicating factor that might put you in a high-risk category
Even if your pregnancy isn't high risk, this may still be a good time to make a change in health care providers if you're not comfortable with your current doctor.
Your First Visit
You should call to schedule your first examination during the first 6 to 8 weeks of your pregnancy, or when your menstrual period is 2 to 4 weeks late. Many health care providers will not schedule the first visit before 8 weeks, unless there is a problem.
During your first visit, you'll be asked a lot of questions about your health and habits that may have an effect on your pregnancy. It's important to try to remember the date of your last menstrual period so your doctor can estimate the duration of your pregnancy and predict your delivery date.
You can expect to have a full physical, including a pelvic and rectal exam. A blood sample will be taken and used for a series of tests:
- a complete blood cell count (CBC)
- blood typing and screening for Rh antibodies (antibodies against a substance found in the red blood cells of most people)
- for infections such as syphilis, hepatitis, gonorrhea, chlamydia, and human immunodeficiency virus (HIV)
- for evidence of previous exposure to chickenpox (varicella), measles (rubeola), mumps, or German measles (rubella)
- for cystic fibrosis (health care providers recently started to offer this even if there's no family history of the disorder)
Some blood tests are offered only to women of certain ethnic backgrounds, who may be at higher risk of carrying genes for specific diseases. For example, women of African or Mediterranean descent are usually tested for thalassemia or sickle cell trait or disease because they're at higher risk of these chronic blood diseases or carrying the sickle cell trait, which can be passed on to their children.
Women of Ashekenazi Jewish heritage (Jews of central and eastern European descent) and women of French-Canadian/Cajun heritage are at increased risk for carrying the genes for Tay-Sachs disease.
Talk with your health care provider to see if any of these genetic tests may be recommended for you.
During the first visit, you also can expect to provide a urine sample for testing and to have a Pap test (or smear) for cervical cancer. To do a Pap smear, the doctor uses what looks like a very long mascara wand or cotton swab to gently scrape the inside of the cervix (the opening to the uterus that's located at the very top of the vagina). This generally doesn't hurt; some women say they feel a little twinge, but it only lasts a second.
Routine Visits and Testing
If you're healthy and there are no complicating risk factors, you can expect to see your health care provider:
- every 4 weeks until the 28th week of pregnancy
- then every 2 weeks until 36 weeks
- then once a week until delivery
At each examination, your weight and blood pressure are usually recorded. The size and shape of your uterus may also be measured, starting at the 22nd week, to determine whether the fetus is growing and developing normally.
During one or more of your visits, you'll provide a small urine sample to be tested for sugar (glucose)and protein. Protein may indicate preeclampsia, a condition that develops in late pregnancy and is characterized by a sudden rise in blood pressure and excessive weight gain, with fluid retention and protein in the urine.
Glucose screening usually takes place at 12 weeks for women who are at higher risk of having gestational diabetes (diabetes that occurs during pregnancy). That includes women who:
- have previously delivered a baby that weighed more than 9 pounds (4.1 kilograms)
- have a family history of diabetes
- are obese
All other pregnant women are tested for diabetes at 24 to 28 weeks. This test involves drinking a sugary liquid and having a blood glucose test (which involves having blood drawn) after an hour. If the sugar level in the blood is high, further testing might be done to diagnose gestational diabetes.
Many expectant parents also choose to have one or more of the following prenatal tests, which can help predict the likelihood of, or sometimes even detect, certain developmental or chromosomal abnormalities in the fetus:
First trimester screening: Between 10 and 14 weeks, your doctor might recommend a blood test to measure two substances — pregnancy-associated plasma protein (PAPP-A) and hCG (human chorionic gonadotropin), both produced by the placenta in early pregnancy. You also might be sent for an ultrasound test for fetal nuchal translucency, which measures the amount of fluid at the back of your developing baby's neck.
Second trimester screening: Between 16 and 18 weeks, the level of alpha-fetoprotein, a protein produced by the fetus, can be measured in a pregnant woman's blood. If the level is high, she may be carrying more than one fetus or a fetus with spina bifida or other neural tube defects. A high level can also indicate that the date of conception was miscalculated. If the level is low, the fetus may have chromosomal abnormalities, such as Down syndrome.
Along with AFP, two hormones produced by the placenta are often measured — hCG and estriol. The level of these three substances can help doctors identify a fetus at risk for certain birth defects or chromosomal abnormalities. When all three are measured, the test is called the triple screen or triple marker. Often a fourth placental hormone is measured, called inhibin-A. In this case, the test might be called the multiple marker screening (or quadruple screen, quad screen, quadruple marker, or quad marker).
Sometimes both first and second trimester screening tests are done. This is called an integrated screening test.
It's important to keep in mind that abnormal results of screening tests don't automatically indicate a problem; rather, they indicate the need for further testing, which yields normal results in many cases.
Additional testing that might be recommended can include the following:
Amniocentesis (also called an amnio): In this test, a needle is used to remove a sample of the amniotic fluid from the womb; it's usually performed between 15 and 20 weeks. Testing the fluid can identify certain fetal abnormalities such as Down syndrome or spina bifida. Typically, amniocentesis is recommended only if there is reason to believe that the risk for such conditions is higher than usual, perhaps due to maternal age (35 or older), abnormal screening results, or family history. Although the test poses a small risk for causing preterm labor and inducing miscarriage, the large majority are performed without any problem.
Chorionic villus sampling (CVS): This procedure is used during the first trimester for the same purposes as an amniocentesis. (Women usually have one or the other, but not both, if such testing is deemed necessary.) It involves taking a sample of the tissue that attaches the amniotic sac (the sac around the fetus) to the wall of the uterus. Like amniocentesis, CVS is typically done only when there are certain risk factors; its primary advantage is that results are available sooner. CVS also carries a slightly increased risk of miscarriage and other complications.
Ultrasound (also called a sonogram, sonograph, echogram, or ultrasonogram): You'll likely have at least one ultrasound examination to make sure the pregnancy is progressing normally and to verify the expected date of delivery. Usually, an ultrasound is performed at 18 to 20 weeks to look at the baby's anatomy, but can be done sooner or later and sometimes more than once. An ultrasound poses no risk to you or your baby.
Some health care providers may have the equipment and trained personnel necessary to provide in-office ultrasounds, whereas others may have you go to a local hospital or radiology center.
Wherever the ultrasound is done, a technician will coat your abdomen with a gel and then run a wand-like instrument over it. High-frequency sound waves "echo" off your body and create a picture of the fetus on a computer screen.
Ultrasound scanning is used to:
- determine whether the fetus is growing at a normal rate
- record fetal heartbeat or breathing movements
- see whether you might be carrying more than one fetus
- identify a variety of abnormalities that might affect the remainder of the pregnancy or delivery
Ultrasounds are sometimes available at shopping malls as a way to have a "portrait" of your baby. However, the individuals using the equipment are not necessarily trained as ultrasound technicians. Before having one of these done, it would be wise to discuss it with your health care provider.
Common Concerns During Pregnancy
Some women are concerned about preexisting medical conditions, such as diabetes, and how they could affect a pregnancy. It's important to discuss these concerns with your doctor, who may recommend a change in medication or treatment approaches that could ease your concerns.
Whether or not you have a preexisting condition, you may be concerned about some of the other conditions that can be associated with pregnancy including:
- gestational diabetes: Up to 8% of pregnant women develop this condition, usually after the first trimester. During pregnancy, the placenta, which provides the fetus with nutrients and oxygen, also produces hormones that change the way insulin works. Insulin, made by the pancreas, helps the body store the sugar in food so that later it can be converted to energy. When someone has gestational diabetes, a problem with insulin also leads to a high blood sugar level.
- preeclampsia (also called toxemia of pregnancy): This abnormal condition develops after the sixth month, causing high blood pressure, edema (fluid buildup in body tissues that causes swelling of the hands, feet, or face), and protein in the urine.
- Rh-negative mother/Rh-positive fetus (also called Rh incompatibility): Rh factor is found in the red blood cells of most people (a simple blood test can determine your Rh factor). If you don't have it, then you're considered Rh negative. If your baby does have the factor and is Rh positive, problems can happen when the baby's blood cells enter your bloodstream. That's because your body may react by producing antibodies that can pass into the fetus' bloodstream and destroy red blood cells.
These conditions are serious but manageable, so it's important to learn about them and discuss them with your health care provider.
About Weight Gain During Pregnancy
Many pregnant women also worry about weight gain. It's generally recommended that a woman of normal weight gain about 25 to 35 pounds during pregnancy. For women who start their pregnancy overweight, total weight gain should be closer to 15 to 25 pounds. And those who are underweight should gain 28 to 40 pounds.
Controlling weight gain is more difficult later in a pregnancy, so try to avoid gaining a lot of weight during the first few months. However, not gaining enough weight can cause problems too, such as inadequate fetal growth and premature labor.
Pregnancy is not a good time to start a diet, but it is a great time to enjoy healthier foods. Doctors generally recommend that women add about 300 calories to their daily intake to provide nourishment for the developing fetus. Although protein should supply most of these calories, your diet should be well balanced and include fresh fruits, grains, and vegetables.
Your health care provider will likely prescribe a prenatal vitamin to make sure you get enough folic acid, iron, and calcium. It's also a good time to get regular, low-impact exercise.
Taking Care of Yourself
For your baby's sake and yours, it's important to take especially good care of yourself during your pregnancy. Follow these basics:
- Don't smoke, drink alcohol, or take drugs.
- Get enough rest.
- Eat a healthy diet.
Over-the-counter medications are generally considered off-limits because of their potential effects on the fetus. Most doctors recommend not taking any OTC medications if possible, but might offer a list of those they think are safe to take. Be sure to discuss any questions about medicines (including natural remedies, supplements, and vitamins) with your doctor.
When you're pregnant, it's also important to avoid foodborne illnesses, such as listeriosis and toxoplasmosis, which can be life threatening to an unborn baby and may cause birth defects or miscarriage. Foods to steer clear of include:
- soft, unpasteurized cheeses (often advertised as "fresh") such as feta, goat, Brie, Camembert, and blue cheese
- unpasteurized milk, juices, and apple cider
- raw eggs or foods containing raw eggs, including mousse and tiramisu
- raw or undercooked meats, fish, or shellfish
- processed meats such as hot dogs and deli meats (these should be well cooked)
You also should avoid eating shark, swordfish, king mackerel, or tilefish. Although fish and shellfish can be an extremely healthy part of your pregnancy diet (they contain beneficial omega-3 fatty acids and are high in protein and low in saturated fat), these types of fish may contain high levels of mercury, which can cause damage to the developing brain of a fetus.
Pregnancy also can cause a number of uncomfortable (but not necessarily serious) side effects, including:
- nausea and vomiting, especially early in the pregnancy
- leg swelling
- varicose veins in the legs and the area around the vaginal opening
- heartburn and constipation
- sleep loss
If you have any of these side effects, you're not alone! Talk to your doctor about ways to ease your discomfort.
Talking to Your Health Care Provider
When your body is going through physical changes that may be completely new to you, it isn't always easy to talk to your health care provider. Maybe you're wondering whether you can have sex or what to do about hemorrhoids or constipation, or maybe you're feeling a great deal of anxiety about the delivery.
You might feel embarrassed to ask these or other questions, but it's important to do so — and remember, your health care provider has heard them all before. Keep a running list of questions between your appointments, and take that list with you to each visit.
Also, call your doctor immediately if you have:
- heavy bleeding
- a sudden loss of fluid
- a noticeable absence of movement by the baby
- more than three contractions in an hour