Unless you’re under the care of a midwife who visits you at home, conception begins a long series of visits to the obstetrician’s office, with the type and frequency of visits as varied as the doctors who attend deliveries. The entire prenatal experience is punctuated by a doctor’s care plan that has developed over the years and is then fine-tuned to the unique presentation of your pregnancy.
There are two types of prenatal populations:
- Those pregnancies where everything is perfect and
- Everyone else!
The perfect pregnancy doesn’t truly exist, but there are the normal and the high-risk—the most generalized divisions of surveillance for an obstetrician watching a pregnancy. Ironically, the “perfect” pregnancy patient gets booted out of the Perfect Pregnancy Club for even the slightest physiologic indiscretion. High blood pressure, spilling protein in the urine, fetal growth abnormalities, an abnormal ultrasound—any number of things will justify moving you from the normal to the high-risk. Of course, that’s what obstetrics is all about: knowing which patients need extra care.
In a normal pregnancy, you can expect your obstetrician to see you every three or four weeks at first, then increase the frequency of visits as your pregnancy advances, until you begin weekly visits in the last month.
The First Trimester
The Normal Pregnancy:
Until the completion of the first 12 weeks of pregnancy, known as the first trimester, there are general medical considerations. This is also the time when miscarriage is most likely, and up to 20 percent of diagnosed pregnancies miscarry due to genetic mishaps at conception. Assuming all is well and in every way unsuspicious, you can expect your normal pregnancy to involve monthly visits that will continue usually until the end of your second trimester (24 weeks).
On your initial visit, a careful history will be obtained or updated. Prior records from your last doctor or from consultants (such as infertility specialists) who have been caring for you will be sent for. If there’s a history of pre-existing conditions—hypertension, irritable bowel disease, diabetes, thyroid, etc.—this will mean you’re out of the “normal” pregnancy group. The initial physical exam will be used to assess your general maternal health, and you should expect initial laboratory tests, vaginal cultures, and a check of the size of your uterus.
Routine cultures will be for chlamydia, gonorrhea, and perhaps group B strep, although the strep culture is usually done around 28 weeks. Expect a Pap smear, because no prenatal care is adequate without one.
The exam should indicate whether there is someone growing inside your uterus making it the size expected for the gestational age. An initial ultrasound might be done during the first trimester to document a normal-appearing fetus, establish agreement or disagreement with the patient’s due date based on a last menstrual period, and to begin the actual bonding process. Except for a change in the due date, which is just arithmetic, any other ultrasound surprises (twins, for instance) will be your ticket out of the “normal” pregnancy group.
Many obstetricians feel comfortable getting two ultrasounds before 20 weeks, because the accuracy of the dating of the pregnancy falls off dramatically in later pregnancy. The first ultrasound is often obtained before 12 weeks. The second one, if done, will be obtained at least a month later so that an expected and appropriate interval-growth can be documented.
During the first trimester, each visit will record the blood pressure, weight, and urine values for sugar (glucose) and protein. Weight becomes important when following a patient with morning sickness. Actual weight loss, which will prompt weekly visits instead of monthly, can result from a severe version of morning sickness called hyperemesis gravidarum. Unless you have chronic hypertension or kidney disease, blood pressure problems or protein in the urine are more likely to be problems that occur in the third trimester.
Since the first trimester is the highest risk miscarriage zone, any bleeding will prompt ultrasounds more often, sometimes even weekly. You’ll be out of the normal group for this as well, and you should then expect serial blood levels of the pregnancy hormone, hCG, to watch for ensuing miscarriage, ectopic pregnancy, or resolution toward a normal pregnancy. Fetal heart tones are often difficult to hear during the first trimester, so hearing the heartbeat will have to wait until the second trimester.
The High-Risk Pregnancy:
Problems that can make you high risk include in the first trimester include:
- Bleeding (threatened miscarriage)
- Chronic hypertension
- History of previous miscarriage, congenital abnormalities, stillbirth, or neonatal death
- Multiple gestation
- Medication exposure (either necessary medication for a pre-existing medical condition or exposure to medicines before a patient knew she was pregnant)
- Thyroid disease
- Alcohol or drug abuse
- Abnormal Pap smear
Pre-existing conditions can make for tricky management of the expecting woman since there’s a baby involved. While some treatments may be safe for you, they may not be for your developing baby. Sometimes the risks have to be weighed against the benefits, with trade-offs involved from the fetal as well as your maternal side.
In summary, the first trimester is important for assessing any history that may prove prophetic for the rest of your pregnancy, watching the weight of the mother and the growth of the fetus, and being alert to miscarriage scares.
The Second Trimester
The Normal Pregnancy:
The second trimester (weeks 12 to 24) is when most pregnant patients feel their best. The miscarriage scare, cramping, and nausea recede, allowing some time before the third trimester brings its own set of concerns and discomforts. Fundal height and fetal heart tones are recorded each visit, with visit intervals ranging between every two to four weeks, depending on your doctor. Blood pressure, weight, and urine surveillance also continue.
The second trimester is normally a quiet time when the generalities of maternal and fetal health and appropriate fetal growth are observed. A free exchange of questions and answers during your visits addresses those things important to you as a prospective mother, and a caregiver’s particular communicative skills will determine the quality of your education as it pertains to your particular pregnancy.
Between 15 and 20 weeks, you should expect to be offered an alpha-fetoprotein (AFP) test to screen for neural tube defects (such as spina bifida) and Down syndrome. If you’re over 35, you will be offered an amniocentesis for genetic studies. (Other genetic studies are available at 10 weeks, such as chorionic villus sampling.)
New and strange pains come and go now as your growing baby competes for space. The baby will win, of course, so shortness of breath, ligament pains, nerve tingling, and other unusual effects occur around this time. Your doctor will begin to look for signs of preterm labor or, if there’s a history of preterm deliveries, incompetent cervix.
Fetal movement, a sign of well-being, usually happens around eighteen weeks. Called “quickening,” the movements become more organized over time, and an obstetrician will be wary of any decreased movement. Problems with movement or appropriate growth will prompt additional ultrasound studies to exonerate the health of your pregnancy.
The High-Risk Pregnancy:
Problems that can make you high risk in the second trimester include:
- The high-risk factors from the first trimester
- Incompetent cervix, increasing the risk of preterm delivery
- Bleeding (due to placental abruption or previa)
- IUGR (Intra-uterine growth restriction–a baby small for the corresponding gestational age
- Gestational diabetes
- Pregnancy-induced hypertension
- Sporadic or non-compliant prenatal care
- Preterm labor
- Kidney infection
- Premature rupture of membranes (or leaking)
- Abdominal tenderness of the uterus (possible infection of the pregnancy)
The Third Trimester
The Normal Pregnancy:
In normal pregnancy, the third trimester is a little longer because there’s a variation in lengths of pregnancies, with “term” considered anywhere from 37 to 42 weeks. A due date is just the middle of the bell curve, and your baby will have his or her own clock, so think of if as your due month.
As you near your due date, a physician or nurse will check your cervix for change—a predictor for how imminent labor is. Some practitioners check as soon as 37 weeks, some not until after the due date.
This is the time for philosophical discussions regarding elective induction, because if there are no medical indications for induction, elective induction should be done only at or after 39 weeks–and you should expect it to be your call. Even though two weeks past the due date is considered the time to act no matter what, extra surveillance should begin right after the due date because your baby keeps growing but the placenta may start dying, and your baby’s needs may outpace the placenta’s ability to deliver.
Non-stress tests and additional ultrasound may be prudent at this time. The third trimester is the time most likely to see pregnancy-related complications of pregnancy-induced hypertension, so signs of this are of the utmost importance. Gestational diabetes is screened for at or around 26 weeks. Group B strep cultures are obtained at around 28 weeks.
The High-Risk Pregnancy:
Problems that can make you high risk in the third trimester include:
- The high-risk factors from the first and second trimesters
- Decreased fetal movement
- Abnormal amount of amniotic fluid
- Emotional abnormalities (pregnancy is a stress that may bring out borderline psychiatric conditions)
- Nausea and/or vomiting—not the typical morning sickness of the first trimester. This late in pregnancy, liver problems may be the cause, from a sneaky PIH variant called HELLP which would prompt immediate delivery to a more benign gallbladder problem which can be addressed after delivery.
- Right upper quadrant pain.
- Decreased “reactivity” on non-stress test, in which the baby’s heart rate does not accelerate after movement, which is the expected norm.
Pregnancy is a condition in which one can be normal one moment and be blindsided by a problem the next. For this reason, every doctor has a routine for keeping an eye out for warning signals in every pregnancy. High-risk patients have a series of appointments tailored just for them. In your visits to your obstetrician, you should expect all of the screenings that this year has to offer—not last year’s obstetrics. You should expect your doctor to follow your pregnancy appropriately, whether you’re high risk or not. And you should expect him or her to know the difference.