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Prenatal care: 1st trimester visits

Pregnancy and prenatal care go hand in hand. During the first trimester, prenatal care includes blood tests, a physical exam, conversations about lifestyle and more.

Prenatal care is an important part of a healthy pregnancy. Whether you choose a family physician, obstetrician, midwife or group prenatal care, here's what to expect during the first few prenatal appointments.

The 1st visit

When you find out you're pregnant, make your first prenatal appointment. Set aside time for the first visit to go over your medical history and talk about any risk factors for pregnancy problems that you may have.

Medical history

Your health care provider might ask about:

Your menstrual cycle, gynecological history and any past pregnancies
Your personal and family medical history
Exposure to anything that could be toxic
Medications you take, including prescription and over-the-counter medications, vitamins or supplements
Your lifestyle, including your use of tobacco, alcohol, caffeine and recreational drugs
Travel to areas where malaria, tuberculosis, Zika virus, mpox — also called monkeypox — or other infectious diseases are common

Share information about sensitive issues, such as domestic abuse or past drug use, too. This will help your health care provider take the best care of you — and your baby.

Your due date is not a prediction of when you will have your baby. It's simply the date that you will be 40 weeks pregnant. Few people give birth on their due dates. Still, establishing your due date — or estimated date of delivery — is important. It allows your health care provider to monitor your baby's growth and the progress of your pregnancy. Your due date also helps with scheduling tests and procedures, so they are done at the right time.

To estimate your due date, your health care provider will use the date your last period started, add seven days and count back three months. The due date will be about 40 weeks from the first day of your last period. Your health care provider can use a fetal ultrasound to help confirm the date. Typically, if the due date calculated with your last period and the due date calculated with an early ultrasound differ by more than seven days, the ultrasound is used to set the due date.

Physical exam

To find out how much weight you need to gain for a healthy pregnancy, your health care provider will measure your weight and height and calculate your body mass index.

Your health care provider might do a physical exam, including a breast exam and a pelvic exam. You might need a Pap test, depending on how long it's been since your last Pap test. Depending on your situation, you may need exams of your heart, lungs and thyroid.

At your first prenatal visit, blood tests might be done to:

Check your blood type. This includes your Rh status. Rh factor is an inherited trait that refers to a protein found on the surface of red blood cells. Your pregnancy might need special care if you're Rh negative and your baby's father is Rh positive.
Measure your hemoglobin. Hemoglobin is an iron-rich protein found in red blood cells that allows the cells to carry oxygen from your lungs to other parts of your body. Hemoglobin also carries carbon dioxide from other parts of your body to your lungs so that it can be exhaled. Low hemoglobin or a low level of red blood cells is a sign of anemia. Anemia can make you feel very tired, and it may affect your pregnancy.
Check immunity to certain infections. This typically includes rubella and chickenpox (varicella) — unless proof of vaccination or natural immunity is documented in your medical history.
Detect exposure to other infections. Your health care provider will suggest blood tests to detect infections such as hepatitis B, syphilis, gonorrhea, chlamydia and HIV , the virus that causes AIDS . A urine sample might also be tested for signs of a bladder or urinary tract infection.

Tests for fetal concerns

Prenatal tests can provide valuable information about your baby's health. Your health care provider will typically offer a variety of prenatal genetic screening tests. They may include ultrasound or blood tests to check for certain fetal genetic problems, such as Down syndrome.

Lifestyle issues

Your health care provider might discuss the importance of nutrition and prenatal vitamins. Ask about exercise, sex, dental care, vaccinations and travel during pregnancy, as well as other lifestyle issues. You might also talk about your work environment and the use of medications during pregnancy. If you smoke, ask your health care provider for suggestions to help you quit.

Discomforts of pregnancy

You might notice changes in your body early in your pregnancy. Your breasts might be tender and swollen. Nausea with or without vomiting (morning sickness) is also common. Talk to your health care provider if your morning sickness is severe.

Other 1st trimester visits

Your next prenatal visits — often scheduled about every four weeks during the first trimester — might be shorter than the first. Near the end of the first trimester — by about 12 to 14 weeks of pregnancy — you might be able to hear your baby's heartbeat with a small device, called a Doppler, that bounces sound waves off your baby's heart. Your health care provider may offer a first trimester ultrasound, too.

Your prenatal appointments are an ideal time to discuss questions you have. During your first visit, find out how to reach your health care team between appointments in case concerns come up. Knowing help is available can offer peace of mind.

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Lockwood CJ, et al. Prenatal care: Initial assessment. https://www.uptodate.com/contents/search. Accessed July 9, 2018.
Prenatal care and tests. Office on Women's Health. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-and-tests. Accessed July 9, 2018.
Cunningham FG, et al., eds. Prenatal care. In: Williams Obstetrics. 25th ed. New York, N.Y.: McGraw-Hill Education; 2018. https://www.accessmedicine.mhmedical.com. Accessed July 9, 2018.
Lockwood CJ, et al. Prenatal care: Second and third trimesters. https://www.uptodate.com/contents/search. Accessed July 9, 2018.
WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/. Accessed July 9, 2018.
Bastian LA, et al. Clinical manifestations and early diagnosis of pregnancy. https://www.uptodate.com/contents/search. Accessed July 9, 2018.

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Routine blood tests during the first trimester of pregnancy

During early pregnancy, you can expect common first trimester blood tests including a complete blood count (CBC), blood type and Rh factor, hepatitis B testing, and screening for sexually transmitted infections. They're all meant to assess your health and that of your developing baby.

1. Blood type, Rh factor, and antibody screening

2. complete blood count, 3. rubella (german measles) immunity, 4. hepatitis b testing, 5. syphilis screening, 6. hiv testing, other blood tests, when will i get the results of the blood tests.

At your first prenatal visit , your practitioner will check your blood type to see whether it's type O, A, B, or AB, and whether it's Rh-negative .

If you're Rh-negative (15 percent of people are), you'll get a shot of Rh immune globulin (Rhogam) at least once during your pregnancy, and another after you give birth if your baby turns out to be Rh-positive.

This shot will protect you from developing antibodies that could be dangerous during this pregnancy or (more likely) in future pregnancies. (In your first pregnancy, your body will make only a small number of antibodies, which may not cause a problem. In later pregnancies, your body will make more.) These antibodies attack fetal red blood cells, causing fetal anemia.

Your blood will also be checked for Rh antibodies as well as some other antibodies that may affect your pregnancy. If you have these at the start of pregnancy, your doctor will monitor the levels with blood work until delivery.

A complete blood count (CBC) will tell your practitioner if you have too little hemoglobin in your red blood cells (a sign of anemia ) and, if so, whether it's likely to be the result of iron deficiency.

If you're iron deficient, your practitioner will recommend that you increase iron in your diet by eating more iron-rich foods (such as lean meat) and taking iron supplements .

The CBC also counts your platelets and white blood cells. (An elevated number of white blood cells could indicate an infection, and the number of platelets can tell if there's a problem with blood clotting.)

This test, called a rubella titer, checks the level of antibodies to the rubella virus in your blood to see whether you're immune. Most women are immune to rubella, either because they've been vaccinated (with the MMR vaccine) or, (more unlikely), had the disease as a child.

If a woman is infected with rubella for the first time during pregnancy, the rubella virus can cause a miscarriage , preterm birth , or stillbirth , as well as a variety of serious birth defects, depending on how far along you are when you contract the virus. So if you aren't immune (either because you never received the vaccine, or its effect waned), it's very important to avoid anyone who has the infection and forgo travel to foreign countries where the disease is still prevalent. (Fortunately, thanks to widespread vaccinations, rubella is rare in the United States.)

Although you can't be vaccinated while you're pregnant, if you're found to be non-immune, get the MMR vaccine after you give birth to protect future pregnancies.

Many women with this liver disease have no symptoms and can unknowingly pass it to their baby during labor or after birth. This test will reveal whether you're a hepatitis B carrier. Most women of reproductive age in the United States have received the hepatitis B vaccine as children and teens and so are immune.

If you're a hepatitis B carrier, your practitioner will protect your baby by giving them an injection of hepatitis B immune globulin as well as their first shot of the hep B vaccine within 12 hours of birth. (Your baby will get the second shot at 1 or 2 months and the third at 6 months.) All members of your household should be tested and vaccinated if you're a carrier. Most babies receive their first hepatitis B vaccine within the first month of life, regardless.

This sexually transmitted infection (STI) is relatively rare today, but all women need to be tested. If you have syphilis and don't treat it, both you and your baby could develop serious problems. In the unlikely event that you test positive, you'll be given antibiotics to treat the infection.

The U.S. Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and a host of other organizations recommend that all pregnant women be tested for the human immunodeficiency virus (HIV) , the virus that causes AIDS.

HIV can pass through the placenta and infect your baby during pregnancy and/or delivery. If you test positive for HIV, you and your baby can get treatment that will help maintain your own health and greatly reduce the chance that your baby will become infected with the virus. Given the test results and time, your doctors can greatly reduce the risk of transmission to your baby. (If your level of HIV virus is high, your doctors may recommend a cesarean delivery to protect your baby from the virus.)

If you're not sure whether you've ever had chicken pox or been vaccinated against it, you can be tested to see if you're immune. Being exposed to this infection for the first time when pregnant may lead to complications.
A glucose challenge test may be done in the first trimester if you're at high risk for diabetes (you're overweight or obese, have a history of gestational diabetes in a previous pregnancy, or a strong family history of diabetes).
First-trimester screening for Down syndrome and some other chromosomal abnormalities is available for all women. This generally involves a blood test as well as an ultrasound to measure the baby's nuchal fold .
Blood tests for carrier status of genetic disorders are available for all women. Depending on your ethnic heritage, certain tests may be specifically recommended. Some of these, like the test that determines whether you're a cystic fibrosis carrier, may be offered to you even if you're not in a high-risk category. You will have multiple options with varying insurance coverage, so be sure to ask your provider about costs.
If you have a history of preeclampsia in a previous pregnancy, or currently have hypertension , your provider may check your kidney and liver functions (as part of your CBC), as well as your urine for protein. This will help establish a baseline in the event these later become abnormal.

Test results can take a week or two, depending on which tests you need.

Unless there's a problem that needs to be addressed right away or you're particularly concerned about a certain test, your practitioner will generally wait until your next appointment to review your test results with you. (If you've had genetic screening and are eager for results, though, your provider will likely call you as soon as they have them.)

Also, many patients now have access to patient portals with lab results made available in a secure online format as soon as they're ready.

Wondering what other tests might be coming up? Here's an overview of prenatal tests that tells you, trimester by trimester, what you might be scheduled for.

Learn More:

NIPT (Noninvasive prenatal testing)
When and how you can find out your baby's sex
Ultrasounds during pregnancy
When can you hear your baby's heartbeat?

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Routine urine tests during pregnancy

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Carrier screening for inherited genetic disorders

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Why would I need a RhoGAM shot during pregnancy?

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Hepatitis B in pregnancy

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BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

ACOG. 2021. Routine tests during pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/patient-resources/faqs/pregnancy/routine-tests-during-pregnancy Opens a new window

ACOG. 2021. Chlamydia, gonorrhea, and syphilis. American College of Obstetricians and Gynecologists. https://www.acog.org/patient-resources/faqs/gynecologic-problems/chlamydia-gonorrhea-and-syphilis Opens a new window

ACOG. 2021. Hepatitis B and hepatitis C in pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/patient-resources/faqs/pregnancy/hepatitis-b-and-hepatitis-c-in-pregnancy Opens a new window

ACOG. 2022. HIV and pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/hiv-and-pregnancy Opens a new window

ACOG. 2022. The Rh factor: How it can affect your pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/the-rh-factor-how-it-can-affect-your-pregnancy Opens a new window

ACOG. 2020. Prenatal genetic screening tests. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/prenatal-genetic-screening-tests Opens a new window

MedlinePlus. 2022. Prenatal care in your first trimester. https://medlineplus.gov/ency/patientinstructions/000544.htm Opens a new window

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Prenatal Panel

What is a prenatal panel.

A prenatal panel is group of blood tests that are done early in pregnancy . The tests are used to check for diseases and infections that can affect the health of a pregnant woman and her unborn baby . The results can guide treatments, which may help prevent serious complications. A prenatal panel usually includes the following tests:

Complete blood count (CBC) . This test measures the different parts and features of your blood, including red blood cells, white blood cells, and platelets. A CBC can help diagnose a variety of health problems, such as anemia , clotting disorders , and infections.
Blood type and Rh factor . This test finds out your blood type (A, B, AB, or O) and checks your Rh factor. Rh factor is a type of protein found on the surface of red blood cells. If your blood cells have this protein, you are Rh positive. If they don't, you are Rh negative. If you are Rh negative and your unborn baby is Rh positive, your body may begin to make antibodies against your baby's blood.
Rubella , also known as German measles, is a viral infection. This test shows if you have immunity to rubella. This means you have been vaccinated against rubella or have been infected with it in the past. If a woman gets infected with rubella during pregnancy, it can put her baby at risk for serious birth defects.
Hepatitis B and C are viruses that infect the liver. The hepatitis virus can be passed from a pregnant woman to her unborn baby. Most pregnant women are tested for hepatitis B . Hepatitis C is not routinely tested, because is not common. But you may be tested if you have certain risk factors.
Sexually transmitted diseases (STDs). Most pregnant women are tested for chlamydia and syphilis early in pregnancy. You may also be tested for gonorrhea if you have certain risk factors. An STD can lead to miscarriage or infect your baby during delivery. An STD can be dangerous to a newborn. It may cause blindness, breathing problems , or other health issues.
HIV is a virus that attacks the immune system and can lead to AIDS (acquired immunodeficiency syndrome). If you have HIV, you may pass along the virus to your unborn baby. Many pregnant women are tested for HIV, and some states require testing.

Other names: obstetric panel, OB panel

What is it used for?

A prenatal panel is used to find health problems early in pregnancy . Many conditions can be treated during pregnancy to avoid complications. The test may also be used to guide treatments for a baby immediately after birth.

Why do I need a prenatal panel?

Your health care provider will probably order these tests as part of a routine prenatal visit . The tests are done in the first trimester of pregnancy, often at the first prenatal visit.

What happens during a prenatal panel?

A health care professional will take a blood sample from a vein in your arm, using a small needle. After the needle is inserted, a small amount of blood will be collected into a test tube or vial. You may feel a little sting when the needle goes in or out. This usually takes less than five minutes.

Will I need to do anything to prepare for these tests?

You don't need any special preparations for a prenatal panel.

Are there any risks to the tests?

There is no risk to your unborn baby and very little risk to you. You may have slight pain or bruising at the spot where the needle was put in, but most symptoms go away quickly.

What do the results mean?

If your results were not normal, you and/or your baby may get treatment to prevent serious health problems. Examples of some abnormal results and treatment include:

Rh incompatibility. You will receive medicine that prevents your body from making antibodies against your baby's red blood cells.
Infections (hepatitis, STDs, HIV). You will receive medicine to treat the infection. If you have a hepatitis B infection, your baby will get a vaccine within a few hours of birth.
No immunity to rubella. You'll need to avoid anyone who has rubella while you are pregnant. After your baby is born, you should get vaccinated.

If you have questions about your results, talk to your health care provider.

Learn more about laboratory tests, references ranges, understanding results .

Is there anything else I need to know about a prenatal panel?

In addition to a prenatal panel, you may also get a urine test during your first trimester. Pregnancy urine tests are used to:

Diagnose a urinary tract infection
Check glucose levels. High levels of glucose in urine may be a sign of gestational diabetes , a type of diabetes that can develop during pregnancy. If your urine glucose was high, your provider may order a blood glucose test to confirm the diagnosis.
Check protein levels. High levels of protein in urine can be a sign of a number of health problems, including kidney disease , infection, or stress . If your urine protein was high, your provider will probably order more tests.
ACOG: The American College of Obstetricians and Gynecologists [Internet]. Washington D.C.: American College of Obstetricians and Gynecologists; c2021. Routine Tests During Pregnancy; 2020 Jun 20 [cited 2021 Mar 29]; [about 3 screens]. Available from: https://www.acog.org/womens-health/faqs/routine-tests-during-pregnancy
ACOG: The American College of Obstetricians and Gynecologists [Internet]. Washington D.C.: American College of Obstetricians and Gynecologists; c2021. The Rh Factor: How It Can Affect Your Pregnancy; 2020 Jun 20 [cited 2021 Mar 29]; [about 3 screens]. Available from: https://www.acog.org/womens-health/faqs/the-rh-factor-how-it-can-affect-your-pregnancy
American Pregnancy Association [Internet]. Irving (TX): American Pregnancy Association; c2021. Understanding Pregnancy Blood Tests; 2012 Apr 25 [cited 2021 Mar 29]; [about 2 screens]. Available from: https://americanpregnancy.org/healthy-pregnancy/pregnancy-health-wellness/blood-test-713
Cigna [Internet]. Bloomfield (CT): Cigna; c2021. Coombs Test; [cited 2021 Mar 29]; [about 4 screens]. Available from: https://www.cigna.com/individuals-families/health-wellness/hw/medical-tests/coombs-test-hw44015
Cigna [Internet]. Bloomfield (CT): Cigna; c2021. Obstetric Panel; [cited 2021 Mar 29]; [about 4 screens]. Available from: https://www.cigna.com/individuals-families/health-wellness/hw/medical-topics/obstetric-panel-tr6158
Lab Tests Online [Internet]. Washington D.C.: LabTestsOnline.org; 2021. Pregnancy: First Trimester (Up to 12 Weeks); [updated 2021 Mar 9; cited 2021 Mar 29]; [about 2 screens]. Available from: https://labtestsonline.org/conditions/pregnancy-first-trimester-12-weeks
National Heart, Lung, and Blood Institute [Internet]. Bethesda (MD): U.S. Department of Health and Human Services; Blood Tests; [cited 2021 Mar 29]; [about 3 screens]. Available from: https://www.nhlbi.nih.gov/health-topics/blood-tests
UF Health: University of Florida Health [Internet]. Gainesville (FL): University of Florida Health; c2021. Prenatal care in your first trimester: Overview; [updated 2021 Mar 29; cited 2021 Mar 29]; [about 2 screens]. Available from: https://ufhealth.org/prenatal-care-your-first-trimester

The information on this site should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

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Prenatal care and tests

Medical checkups and screening tests help keep you and your baby healthy during pregnancy. This is called prenatal care. It also involves education and counseling about how to handle different aspects of your pregnancy. During your visits, your doctor may discuss many issues, such as healthy eating and physical activity, screening tests you might need, and what to expect during labor and delivery.

Choosing a prenatal care provider

You will see your prenatal care provider many times before you have your baby. So you want to be sure that the person you choose has a good reputation, and listens to and respects you. You will want to find out if the doctor or midwife can deliver your baby in the place you want to give birth , such as a specific hospital or birthing center. Your provider also should be willing and able to give you the information and support you need to make an informed choice about whether to breastfeed or bottle-feed.

Health care providers that care for women during pregnancy include:

Obstetricians (OB) are medical doctors who specialize in the care of pregnant women and in delivering babies. OBs also have special training in surgery so they are also able to do a cesarean delivery . Women who have health problems or are at risk for pregnancy complications should see an obstetrician. Women with the highest risk pregnancies might need special care from a maternal-fetal medicine specialist .
Family practice doctors are medical doctors who provide care for the whole family through all stages of life. This includes care during pregnancy and delivery, and following birth. Most family practice doctors cannot perform cesarean deliveries.
A certified nurse-midwife (CNM) and certified professional midwife (CPM) are trained to provide pregnancy and postpartum care. Midwives can be a good option for healthy women at low risk for problems during pregnancy, labor, or delivery. A CNM is educated in both nursing and midwifery. Most CNMs practice in hospitals and birth centers. A CPM is required to have experience delivering babies in home settings because most CPMs practice in homes and birthing centers. All midwives should have a back-up plan with an obstetrician in case of a problem or emergency.

Ask your primary care doctor, friends, and family members for provider recommendations. When making your choice, think about:

Personality and bedside manner
The provider's gender and age
Office location and hours
Whether you always will be seen by the same provider during office checkups and delivery
Who covers for the provider when she or he is not available
Where you want to deliver
How the provider handles phone consultations and after-hour calls

What is a doula?

A doula (DOO-luh) is a professional labor coach, who gives physical and emotional support to women during labor and delivery. They offer advice on breathing, relaxation, movement, and positioning. Doulas also give emotional support and comfort to women and their partners during labor and birth. Doulas and midwives often work together during a woman's labor. A recent study showed that continuous doula support during labor was linked to shorter labors and much lower use of:

Pain medicines
Oxytocin (ok-see-TOHS-uhn) (medicine to help labor progress)
Cesarean delivery

Check with your health insurance company to find out if they will cover the cost of a doula. When choosing a doula, find out if she is certified by Doulas of North America (DONA) or another professional group.

Places to deliver your baby

Many women have strong views about where and how they'd like to deliver their babies. In general, women can choose to deliver at a hospital, birth center, or at home. You will need to contact your health insurance provider to find out what options are available. Also, find out if the doctor or midwife you are considering can deliver your baby in the place you want to give birth.

Hospitals are a good choice for women with health problems, pregnancy complications, or those who are at risk for problems during labor and delivery. Hospitals offer the most advanced medical equipment and highly trained doctors for pregnant women and their babies. In a hospital, doctors can do a cesarean delivery if you or your baby is in danger during labor. Women can get epidurals or many other pain relief options. Also, more and more hospitals now offer on-site birth centers, which aim to offer a style of care similar to standalone birth centers.

Questions to ask when choosing a hospital:

Is it close to your home?
Is a doctor who can give pain relief, such as an epidural, at the hospital 24-hours a day?
Do you like the feel of the labor and delivery rooms?
Are private rooms available?
How many support people can you invite into the room with you?
Does it have a neonatal intensive care unit (NICU) in case of serious problems with the baby?
Can the baby stay in the room with you?
Does the hospital have the staff and set-up to support successful breastfeeding?
Does it have an on-site birth center?

Birth or birthing centers give women a "homey" environment in which to labor and give birth. They try to make labor and delivery a natural and personal process by doing away with most high-tech equipment and routine procedures. So, you will not automatically be hooked up to an IV. Likewise, you won't have an electronic fetal monitor around your belly the whole time. Instead, the midwife or nurse will check in on your baby from time to time with a handheld machine. Once the baby is born, all exams and care will occur in your room. Usually certified nurse-midwives, not obstetricians, deliver babies at birth centers. Healthy women who are at low risk for problems during pregnancy, labor, and delivery may choose to deliver at a birth center.

Women can not receive epidurals at a birth center, although some pain medicines may be available. If a cesarean delivery becomes necessary, women must be moved to a hospital for the procedure. After delivery, babies with problems can receive basic emergency care while being moved to a hospital.

Many birthing centers have showers or tubs in their rooms for laboring women. They also tend to have comforts of home like large beds and rocking chairs. In general, birth centers allow more people in the delivery room than do hospitals.

Birth centers can be inside of hospitals, a part of a hospital or completely separate facilities. If you want to deliver at a birth center, make sure it meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers. Accredited birth centers must have doctors who can work at a nearby hospital in case of problems with the mom or baby. Also, make sure the birth center has the staff and set-up to support successful breastfeeding.

Homebirth is an option for healthy pregnant women with no risk factors for complications during pregnancy, labor or delivery. It is also important women have a strong after-care support system at home. Some certified nurse midwives and doctors will deliver babies at home. Many health insurance companies do not cover the cost of care for homebirths. So check with your plan if you'd like to deliver at home.

Homebirths are common in many countries in Europe. But in the United States, planned homebirths are not supported by the American Congress of Obstetricians and Gynecologists (ACOG). ACOG states that hospitals are the safest place to deliver a baby. In case of an emergency, says ACOG, a hospital's equipment and highly trained doctors can provide the best care for a woman and her baby.

If you are thinking about a homebirth, you need to weigh the pros and cons. The main advantage is that you will be able to experience labor and delivery in the privacy and comfort of your own home. Since there will be no routine medical procedures, you will have control of your experience.

The main disadvantage of a homebirth is that in case of a problem, you and the baby will not have immediate hospital/medical care. It will have to wait until you are transferred to the hospital. Plus, women who deliver at home have no options for pain relief.

To ensure your safety and that of your baby, you must have a highly trained and experienced midwife along with a fail-safe back-up plan. You will need fast, reliable transportation to a hospital. If you live far away from a hospital, homebirth may not be the best choice. Your midwife must be experienced and have the necessary skills and supplies to start emergency care for you and your baby if need be. Your midwife should also have access to a doctor 24 hours a day.

Prenatal checkups

During pregnancy, regular checkups are very important. This consistent care can help keep you and your baby healthy, spot problems if they occur, and prevent problems during delivery. Typically, routine checkups occur:

Once each month for weeks four through 28
Twice a month for weeks 28 through 36
Weekly for weeks 36 to birth

Women with high-risk pregnancies need to see their doctors more often.

At your first visit your doctor will perform a full physical exam, take your blood for lab tests, and calculate your due date. Your doctor might also do a breast exam, a pelvic exam to check your uterus (womb), and a cervical exam, including a Pap test. During this first visit, your doctor will ask you lots of questions about your lifestyle, relationships, and health habits. It's important to be honest with your doctor.

After the first visit, most prenatal visits will include:

Checking your blood pressure and weight
Checking the baby's heart rate
Measuring your abdomen to check your baby's growth

You also will have some routine tests throughout your pregnancy, such as tests to look for anemia , tests to measure risk of gestational diabetes , and tests to look for harmful infections.

Become a partner with your doctor to manage your care. Keep all of your appointments — every one is important! Ask questions and read to educate yourself about this exciting time.

Monitor your baby's activity

After 28 weeks, keep track of your baby's movement. This will help you to notice if your baby is moving less than normal, which could be a sign that your baby is in distress and needs a doctor's care. An easy way to do this is the "count-to-10" approach. Count your baby's movements in the evening — the time of day when the fetus tends to be most active. Lie down if you have trouble feeling your baby move. Most women count 10 movements within about 20 minutes. But it is rare for a woman to count less than 10 movements within two hours at times when the baby is active. Count your baby's movements every day so you know what is normal for you. Call your doctor if you count less than 10 movements within two hours or if you notice your baby is moving less than normal. If your baby is not moving at all, call your doctor right away.

Prenatal tests

Tests are used during pregnancy to check your and your baby's health. At your fist prenatal visit, your doctor will use tests to check for a number of things, such as:

Your blood type and Rh factor
Infections, such as toxoplasmosis and sexually transmitted infections (STIs), including hepatitis B , syphilis , chlamydia , and HIV
Signs that you are immune to rubella (German measles) and chicken pox

Throughout your pregnancy, your doctor or midwife may suggest a number of other tests, too. Some tests are suggested for all women, such as screenings for gestational diabetes, Down syndrome, and HIV. Other tests might be offered based on your:

Personal or family health history
Ethnic background
Results of routine tests

Some tests are screening tests. They detect risks for or signs of possible health problems in you or your baby. Based on screening test results, your doctor might suggest diagnostic tests. Diagnostic tests confirm or rule out health problems in you or your baby.

Understanding prenatal tests and test results

If your doctor suggests certain prenatal tests, don't be afraid to ask lots of questions. Learning about the test, why your doctor is suggesting it for you, and what the test results could mean can help you cope with any worries or fears you might have. Keep in mind that screening tests do not diagnose problems. They evaluate risk. So if a screening test comes back abnormal, this doesn't mean there is a problem with your baby. More information is needed. Your doctor can explain what test results mean and possible next steps.

Avoid keepsake ultrasounds

You might think a keepsake ultrasound is a must-have for your scrapbook. But, doctors advise against ultrasound when there is no medical need to do so. Some companies sell "keepsake" ultrasound videos and images. Although ultrasound is considered safe for medical purposes, exposure to ultrasound energy for a keepsake video or image may put a mother and her unborn baby at risk. Don't take that chance.

High-risk pregnancy

Pregnancies with a greater chance of complications are called "high-risk." But this doesn't mean there will be problems. The following factors may increase the risk of problems during pregnancy:

Very young age or older than 35
Overweight or underweight
Problems in previous pregnancy
Health conditions you have before you become pregnant, such as high blood pressure , diabetes , autoimmune disorders , cancer , and HIV
Pregnancy with twins or other multiples

Health problems also may develop during a pregnancy that make it high-risk, such as gestational diabetes or preeclampsia . See Pregnancy complications to learn more.

Women with high-risk pregnancies need prenatal care more often and sometimes from a specially trained doctor. A maternal-fetal medicine specialist is a medical doctor that cares for high-risk pregnancies.

If your pregnancy is considered high risk, you might worry about your unborn baby's health and have trouble enjoying your pregnancy. Share your concerns with your doctor. Your doctor can explain your risks and the chances of a real problem. Also, be sure to follow your doctor's advice. For example, if your doctor tells you to take it easy, then ask your partner, family members, and friends to help you out in the months ahead. You will feel better knowing that you are doing all you can to care for your unborn baby.

Paying for prenatal care

Pregnancy can be stressful if you are worried about affording health care for you and your unborn baby. For many women, the extra expenses of prenatal care and preparing for the new baby are overwhelming. The good news is that women in every state can get help to pay for medical care during their pregnancies. Every state in the United States has a program to help. Programs give medical care, information, advice, and other services important for a healthy pregnancy.

Learn more about programs available in your state.

You may also find help through these places:

Local hospital or social service agencies – Ask to speak with a social worker on staff. She or he will be able to tell you where to go for help.
Community clinics – Some areas have free clinics or clinics that provide free care to women in need.
Women, Infants and Children (WIC) Program – This government program is available in every state. It provides help with food, nutritional counseling, and access to health services for women, infants, and children.
Places of worship

More information on prenatal care and tests

Explore other publications and websites

Chorionic Villus Sampling (CVS) (Copyright © March of Dimes) - Chorionic villus sampling (CVS) is a prenatal test that can diagnose or rule out certain birth defects. The test is generally performed between 10 and 12 weeks after a woman's last menstrual period. This fact sheet provides information about this test, and how the test sample is taken.
Folic Acid (Copyright © March of Dimes) - This fact sheet stresses the importance of getting higher amounts of folic acid during pregnancy in order to prevent neural tube defects in unborn children.
Folic Acid: Questions and Answers - The purpose of this question and answer sheet is to educate women of childbearing age on the importance of consuming folic acid every day to reduce the risk of spina bifida.
For Women With Diabetes: Your Guide to Pregnancy - This booklet discusses pregnancy in women with diabetes. If you have type 1 or type 2 diabetes and you are pregnant or hoping to get pregnant soon, you can learn what to do to have a healthy baby. You can also learn how to take care of yourself and your diabetes before, during, and after your pregnancy.
Genetics Home Reference - This website provides information on specific genetic conditions and the genes or chromosomes responsible for these conditions.
Guidelines for Vaccinating Pregnant Women - This publication provides information on routine and other vaccines and whether they are recommended for use during pregnancy.
How Your Baby Grows (Copyright © March of Dimes) - This site provides information on the development of your baby and the changes in your body during each month of pregnancy. In addition, for each month, it provides information on when to go for prenatal care appointments and general tips to take care of yourself and your baby.
Pregnancy Registries - Pregnancy registries help women make informed and educated decisions about using medicines during pregnancy. If you are pregnant and currently taking medicine — or have been exposed to a medicine during your pregnancy — you may be able to participate and help in the collection of this information. This website provides a list of pregnancy registries that are enrolling pregnant women.
Pregnancy, Breastfeeding, and Bone Health - This publication provides information on pregnancy-associated osteoporosis, lactation and bone loss, and what you can do to keep your bones healthy during pregnancy.
Prenatal Care: First-Trimester Visits (Copyright © Mayo Foundation) - This fact sheet explains what to expect during routine exams with your doctor. In addition, if you have a condition that makes your pregnancy high-risk, special tests may be performed on a regular basis to check the baby's health.
Ten Tips for a Healthy Pregnancy (Copyright © Lamaze International) - This easy-to-read fact sheet provides 10 simple recommendations to help mothers have a healthy pregnancy.
Ultrasound (Copyright © March of Dimes) - This fact sheet discusses the use of an ultrasound in prenatal care at each trimester.

Connect with other organizations

American Academy of Family Physicians
American Association of Birth Centers
American College of Obstetricians and Gynecologists
Center for Research on Reproduction and Women's Health, University of Pennsylvania Medical Center
Dona International
March of Dimes
Maternal and Child Health Bureau, HRSA, HHS
National Association for Down Syndrome
National Center on Birth Defects and Developmental Disabilities, CDC
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First-Trimester Exams and Tests

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At each prenatal visit during your first trimester, you'll be weighed and have your blood pressure checked. Your urine may also be checked for bacteria, protein, or sugar.

As early as weeks 10 to 12, you may be able to hear your baby's heartbeat using a Doppler ultrasound . By the 20th week, the heart tone is strong enough to hear with a special type of stethoscope.

Depression screening

Your care provider may ask questions about your health and your feelings to find out if you're depressed. Depression is common during pregnancy and after giving birth (postpartum). Experts recommend that all pregnant women be screened for depression. If it isn't treated, depression can cause problems during pregnancy and after birth.

Testing for genetic conditions and birth defects

You can choose whether to have tests for certain conditions, such as Down syndrome . First-trimester tests can be done around 10 to 13 weeks of pregnancy. Options include:

First-trimester screening. This includes blood tests and a certain type of ultrasound. These tests can also be done as part of an integrated screening test.
Chorionic villus sampling (CVS) . This test can be done to find certain genetic conditions.

If you have your first prenatal visit during your second trimester, you'll have more than these tests. Other tests you may have include tests for blood type, anemia, and HIV . You may be screened for hepatitis B, sexually transmitted infections, or thyroid disease. You'll also be checked for past infections, such as syphilis or rubella (German measles) .

Related Information

Current as of: July 10, 2023

Author: Healthwise Staff Clinical Review Board All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

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Author: Healthwise Staff

Clinical Review Board All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

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The Health Encyclopedia contains general health information. Not all treatments or services described are covered benefits for Kaiser Permanente members or offered as services by Kaiser Permanente. For a list of covered benefits, please refer to your Evidence of Coverage or Summary Plan Description. For recommended treatments, please consult with your health care provider.

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Your First Prenatal Appointment

Medical review policy, latest update:.

Medically reviewed for accuracy.

When should I schedule my first prenatal visit?

When will my first prenatal visit take place, read this next, how should i prepare for my first pregnancy appointment, what will happen at my first prenatal visit, will i see my baby on an ultrasound at my first prenatal visit, updates history, jump to your week of pregnancy, trending on what to expect, signs of labor, pregnancy calculator, ⚠️ you can't see this cool content because you have ad block enabled., top 1,000 baby girl names in the u.s., top 1,000 baby boy names in the u.s., braxton hicks contractions and false labor.

ADAM J. ZOLOTOR, MD, DrPH, AND MARTHA C. CARLOUGH, MD, MPH

A more recent article on prenatal care is available.

This is an updated version of the article that appeared in print.

Am Fam Physician. 2014;89(3):199-208

Author disclosure: No relevant financial affiliations.

Many elements of routine prenatal care are based on tradition and lack a firm evidence base; however, some elements are supported by more rigorous studies. Correct dating of the pregnancy is critical to prevent unnecessary inductions and to allow for accurate treatment of preterm labor. Physicians should recommend folic acid supplementation to all women as early as possible, preferably before conception, to reduce the risk of neural tube defects. Administration of Rh o (D) immune globulin markedly decreases the risk of alloimmunization in an RhD-negative woman carrying an RhD-positive fetus. Screening and treatment for iron deficiency anemia can reduce the risks of preterm labor, intrauterine growth retardation, and perinatal depression. Testing for aneuploidy and neural tube defects should be offered to all pregnant women with a discussion of the risks and benefits. Specific genetic testing should be based on the family histories of the patient and her partner. Physicians should recommend that pregnant women receive a vaccination for influenza, be screened for asymptomatic bacteriuria, and be tested for sexually transmitted infections. Testing for group B streptococcus should be performed between 35 and 37 weeks' gestation. If test results are positive or the patient has a history of group B streptococcus bacteriuria during pregnancy, intrapartum antibiotic prophylaxis should be administered to reduce the risk of infection in the infant. Intramuscular or vaginal progesterone should be considered in women with a history of spontaneous preterm labor, preterm premature rupture of membranes, or shortened cervical length (less than 2.5 cm). Screening for diabetes should be offered to all pregnant women between 24 and 28 weeks' gestation. Women at risk of preeclampsia should be offered low-dose aspirin prophylaxis, as well as calcium supplementation if dietary calcium intake is low. Induction of labor may be considered between 41 and 42 weeks' gestation.

Over the past 75 years, the number of U.S. women receiving prenatal care has steadily increased. 1 Family physicians provide integrated prenatal care, including evidence-based screening, counseling, medical care, and psychosocial support. There is uncertainty about the critical elements of prenatal care and education, but inadequate care is associated with increased complications. 2 – 4

Although women in developed countries often have seven to 12 prenatal visits, a multinational trial showed that decreasing the visits to a minimum of four did not increase adverse outcomes, although it slightly decreased patient satisfaction with care. 5 Prenatal care that is provided by a small team; is coordinated; and follows an evidence-based, informed process results in fewer prenatal admissions, improved prenatal education, and greater satisfaction with care. 6 , 7

Physical Examination and Counseling

Standard elements of prenatal care include a routine physical examination (including pelvic examination) at the initial visit, maternal weight and blood pressure at all visits, fetal heart rate auscultation after 10 to 12 weeks with a Doppler monitor or after 20 weeks with a fetoscope, fundal height after 20 weeks, and fetal lie by 36 weeks. 8 , 9 Table 1 includes components of routine prenatal visits. 6 , 9 – 11

A pelvic examination at the initial visit is useful in detecting reproductive tract abnormalities and to screen for sexually transmitted infections. Routine pelvimetry is not useful. 11 Papanicolaou smears should be offered during prenatal care at recommended intervals based on age and Papanicolaou smear history, but do not need to be repeated during pregnancy. 12 Although promotion of breastfeeding is critical, there is no clear evidence to support clinical breast examinations. However, breast examinations may help to proactively address breastfeeding concerns or problems. 13 Although assessment of fundal height and fetal heart tones at every visit is recommended in multiple guidelines, the effect on outcomes is not clear. 6 , 9 , 10

Early body mass index measurement, using prepregnancy height and weight, is important to guide further nutritional counseling and to address the risks of obesity and diabetes. 14 Measurement of blood pressure at each prenatal visit will identify chronic hypertension and hypertensive disorders that may develop during pregnancy, such as preeclampsia and gestational hypertension. 6 These disorders are often asymptomatic.

Periodontal disease is associated with increased risk of preterm birth, and an oral examination is often included in the first prenatal visit. However, treatment does not change outcomes. 15

Pregnant women should be counseled about proper diet, as well as folic acid supplementation. Table 2 summarizes dietary guidelines for pregnant women. 6 , 9 , 10 , 16 Table 3 includes other counseling topics during prenatal care. 6 , 9 – 11 , 17 , 18

Dating of Pregnancy and Routine Ultrasonography

Accurate dating as early as possible in the pregnancy is important for scheduling screening tests and planning for delivery. 6 – 9 Estimated date of confinement is based on the first day of the last menstrual period plus 280 days. Urine pregnancy tests qualitatively test for beta subunit of human chorionic gonadotropin and are usually positive within one week of missed menses. 19

Early ultrasonography should be performed if the patient has irregular cycles or bleeding, if the patient is uncertain of the timing of her last menstrual period, or if there is a discrepancy in the size of her uterus compared with the gestational age. Ultrasonography can accurately date the pregnancy, evaluate for multiple gestation, and reduce the likelihood of unnecessary labor induction for postterm pregnancy. 20 , 21 Ultrasound dating is considered accurate to within four to seven days in the first trimester, 10 to 14 days in the second trimester, and 21 days in the third trimester. 9 , 21 Pregnancy dating should be confirmed with auscultation of fetal heart tones between 10 and 12 weeks, and with fetal quickening between 16 and 18 weeks in women who have been pregnant before or between 18 and 19 weeks in first pregnancies.

A randomized trial comparing routine screening ultrasonography (between 15 and 22 weeks and again at 31 to 35 weeks) performed only for medical indications showed no difference in perinatal outcomes (e.g., fetal or neonatal death, neonatal morbidity). 22 A recent Cochrane review, however, showed that ultrasonography before 24 weeks reduces missed multiple gestation and inductions for postterm pregnancies. 21 There is no other scientific support for routine ultrasonography in uncomplicated pregnancies. It is the standard of care in most U.S. communities to offer a single ultrasound examination at 18 to 20 weeks' gestation, even if dating confirmation is not needed. 11 This is the optimal time for fetal anatomic screening, 23 although the sensitivity of ultrasonography for structural anomalies is poor (overall sensitivity from 11 studies = 24.1%, range = 13.5% to 85.7%). 6

Alloimmunization

The risk of developing alloimmunization for an RhD-negative woman carrying an RhD-positive fetus is approximately 1.5%. This risk can be reduced to 0.2% with Rh o (D) immune globulin (RhoGam). 6 , 11 , 24 Testing for ABO blood group and RhD antibodies should be performed early in pregnancy. Rh o (D) immune globulin, 300 mcg, is recommended for nonsensitized women at 28 weeks' gestation, and again within 72 hours of delivery if the infant has RhD-positive blood. 25

Rh o (D) immune globulin should also be administered if the risk of fetal-to-maternal transfusion is increased (e.g., with chorionic villus sampling, amniocentesis, external cephalic version, abdominal trauma, or bleeding in the second or third trimester). Although alloimmunization is uncommon before 12 weeks' gestation, women with a threatened early spontaneous abortion may be offered Rh o (D) immune globulin, 50 mcg. 25

Iron deficiency anemia is associated with an increased risk of preterm labor, intrauterine growth retardation, and perinatal depression. 26 All pregnant women should be screened for anemia early in pregnancy and treated with supplemental iron if indicated. 6 , 9 , 26

The U.S. Preventive Services Task Force has found insufficient evidence to recommend for or against routine iron supplementation. 27 Multivitamins alone have demonstrated no benefit over iron and folate supplementation. 28 Pregnant women with anemia other than iron deficiency or who do not respond to iron supplementation within four to six weeks should be evaluated for other conditions, including malabsorption, ongoing blood loss, thalassemia, or other chronic diseases.

Genetic Testing and Neural Tube Defects

Down syndrome (trisomy 21 syndrome) occurs in one per 1,440 births in women 20 years of age and one per 32 births in women 45 years of age. 29 Most organizations recommend that all pregnant women be offered aneuploidy screening. Traditional serum screening for Down syndrome is complicated by high false-positive rates (90% to 95% of positive results are false). False-negative results are also possible. Patients should be given sufficient information to make an informed decision. 30

Invasive genetic testing (amniocentesis or chorionic villous sampling) should be offered to women who are 35 years or older. At 35 years of age, the risk of Down syndrome (one per 338 births) is similar to that of fetal loss due to amniocentesis. 29 It is common to offer invasive testing to women 35 years and older without first performing screening tests; however, screening tests can be used for risk stratification to help a woman decide if she wants invasive testing. 6 , 11 Options for aneuploidy screening include nuchal translucency testing with serum testing (nine to 11 weeks' gestation) and later serum testing alone (15 to 19 weeks' gestation). There are a variety of combinations of such tests, and results are generally reported as the risk of aneuploidy. All screening tests have a positive rate of approximately 5% (most of which are false positives) and a detection rate of 69% to 87%. 6 , 11 Table 4 compares screening tests for Down syndrome. 29

If a screening test is positive for Down syndrome, the woman should be offered amniocentesis (15 weeks' gestation or later) or chorionic villous sampling (11 to 13 weeks). The rates of excess fetal loss with these two procedures are similar. 29 In centers where both procedures are available, women can consider earlier genetic testing options. 6 , 11

A combination of serum and nuchal translucency testing can also screen for other trisomy syndromes, such as 13 and 18. Most laboratories can report the risk of trisomy 18 syndrome using serum testing. Protocols for the detection of other trisomies can detect a large portion of these anomalies. These protocols have lower sensitivities (60%) and higher specificities (99%), but similar positive predictive values or rates of false positives, compared with protocols for trisomy 21 screening, because these conditions are much more rare. 29

A new technology, noninvasive prenatal diagnosis, offers the possibility of screening for aneuploidies and other conditions by identifying fragments of fetal DNA in maternal circulation. Early studies have shown a sensitivity for Down syndrome of 100% and a specificity of 99.3%. 31 Currently, cost is high and insurance coverage variable, but this may represent an emerging step in sequential genetic testing.

Other genetic screening should be based on the family histories of the patient and her partner. Genetic risk considerations include cystic fibrosis in whites; Tay-Sachs disease in Ashkenazi Jews, Cajuns, and French Canadians; Canavan disease in Ashkenazi Jews; sickle cell disease in Africans; and thalassemias in Africans, East Indians, Hispanics, Mediterraneans, Middle Easterners, and Southeast Asians. 6 , 10 , 11

Neural tube defects affect 1.5 per 1,000 pregnancies and can be detected by testing maternal serum α-fetoprotein levels (sensitivity = 85.7%, specificity = 97.6%). 6 Folic acid supplementation should be recommended early, preferably before conception. 6 , 9 , 11 , 16 Folic acid, 400 mcg daily, started before pregnancy and continued until six to 12 weeks' gestation reduces the rate of neural tube defects by nearly 75%. 6 Women taking folic acid antagonists or who have a history of carrying a fetus with a neural tube defect should take 4 mg of folic acid daily. 16

Thyroid Testing

Thyroid-stimulating hormone levels should be measured in women with a history of thyroid disease or symptoms of disease in pregnancy, although there is no evidence that universal testing during pregnancy improves outcomes. 32 There is concern that subclinical hypothyroidism in pregnant women may increase the risk of neurodevelopmental delays in infants, but the effectiveness of levothyroxine therapy has not been demonstrated. 33 A large randomized trial comparing thyroid-stimulating hormone measurement before 16 weeks' gestation and after birth found no differences in children's IQ scores at three years of age. 34 If the thyroid-stimulating hormone level is abnormal, a free thyroxine test may be useful.

Women with overt hypothyroidism, which complicates one to three per 1,000 pregnancies, are at increased risk of pregnancy loss, preeclampsia, low birth weight, and fetal demise or stillbirth. Hyperthyroidism occurs in two per 1,000 pregnancies and is associated with pregnancy loss, preeclampsia, low birth weight, thyroid storm, prematurity, and congestive heart failure. 32

Infectious Diseases

Bacterial vaginosis.

Universal screening for bacterial vaginosis is not supported by current evidence. A recent systematic review found that screening and subsequent treatment of infection does not prevent delivery before 37 weeks' gestation, but decreases the risk of low birth weight and premature rupture of membranes. 35

Women should be screened for rubella immunity during the first prenatal visit, ideally before conception when vaccination is safe. All women who are nonimmune should be offered vaccination postpartum to prevent congenital rubella syndrome in subsequent pregnancies. Vaccination should not be given during pregnancy, but may be given during lactation. 6 , 9 , 11

Maternal varicella (chickenpox) can have significant fetal effects, including congenital varicella syndrome (low birth weight and limb, ophthalmologic, and neurologic abnormalities) and neonatal varicella; infection can occur from approximately five days before to two days after birth. Maternal shingles is not a risk for the infant because of passive maternal immunity. There is some evidence to support assessing the mother's varicella history at the first prenatal visit, with serologic testing for those with a negative history. Women who test negative for immunoglobulin G should avoid exposure to varicella during pregnancy and be offered vaccination postpartum. 36 After a significant exposure, varicella-zoster immune globulin therapy may be considered if available. 37

ASYMPTOMATIC BACTERIURIA

Asymptomatic bacteriuria complicates 2% to 7% of pregnancies. All pregnant women should be screened between 11 and 16 weeks' gestation and treated, if positive, to reduce the risk of recurrent urinary tract infection, pyelonephritis, and preterm labor. 6 , 9 , 11 , 38

Physicians should recommend that all pregnant women receive vaccination for influenza. 9 , 11 , 39 Pregnant women may be at higher risk of influenza complications than the general population. 40 Household contacts of pregnant women should also be offered vaccination.

TETANUS AND PERTUSSIS

Women should receive a diphtheria, tetanus, and pertussis (Tdap) vaccine during each pregnancy. The best time for vaccination is between 27 and 36 weeks' gestation for antibody response and passive immunity to the fetus; however, the vaccine may be given any time during pregnancy. 39

GROUP B STREPTOCOCCUS

Group B streptococcus causes significant neonatal morbidity and mortality, particularly among premature infants, and all pregnant women should be offered screening. 9 , 11 , 41 Increased screening at 35 to 37 weeks' gestation and treatment with intrapartum antibiotic prophylaxis (penicillin, or clindamycin if allergic) for those who are positive (10% to 30%) have decreased neonatal mortality in the past decade. 41 Intrapartum treatment is also recommended for women with group B streptococcus bacteriuria occurring at any stage of pregnancy, and for women with unknown group B streptococcus status and risk factors (e.g., preterm birth before 37 weeks' gestation, rupture of membranes more than 18 hours before delivery, or intrapartum fever), and for women with a history of group B streptococcus bacteriuria during pregnancy. 41

SEXUALLY TRANSMITTED INFECTIONS

Many sexually transmitted infections can affect a fetus, warranting routine screening in pregnancy. Table 5 summarizes sexually transmitted infections in pregnancy. 42 – 46

OTHER INFECTIONS

Routine screening for other infections, including toxoplasmosis, cytomegalovirus, and parvovirus, is not recommended during pregnancy. 47 Women should be counseled on decreasing risk of exposure to parvovirus B19, and antibody testing should be considered if there is a significant exposure. 48

Psychosocial Issues

Domestic violence.

Domestic violence during pregnancy increases the risk of complications, such as spontaneous abortion, placental abruption, premature rupture of membranes, low birth weight, and prematurity. 49 Domestic violence–related homicide is the leading cause of death among pregnant women in the United States. 49

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide intervention services or a referral if a woman screens positive. 50 Family physicians should be aware of the signs of abuse in pregnant women, the effect of violence on health, and the increased risk of child abuse after delivery. 51

DEPRESSION SCREENING

The American College of Obstetricians and Gynecologists (ACOG) supports depression screening during pregnancy. 52 Perinatal depression is underdiagnosed and complicates 10% to 15% of pregnancies, resulting in significant morbidity for the mother and infant. Complications include prematurity, low birth weight, neurodevelopmental delays, and issues with maternal/infant bonding.

A number of screening tools are available with similar validity and sensitivity. Untreated depression may result in poor prenatal care; inadequate nutrition; and increased alcohol, drug, and tobacco use. 53

Complications of Pregnancy

Gestational diabetes.

Gestational diabetes complicates 2% to 5% of pregnancies and is associated with hypertensive disorders, macrosomia, shoulder dystocia, and cesarean deliveries. 9 , 11 In addition, the increasing prevalence of undiagnosed type 2 diabetes mellitus and insulin resistance in the general population means many women will first show signs of diabetes during pregnancy. Screening protocols, diagnostic criteria, and treatment criteria are controversial, but diagnosing diabetes earlier in pregnancy and decreasing hyperglycemia improves some pregnancy outcomes. 54 ACOG, in collaboration with the USPSTF, recommends screening for overt diabetes early in pregnancy in those who are at risk (i.e., previous history of gestational diabetes, obesity, or known glucose intolerance) using A1C or fasting blood glucose levels, and screening in all pregnant women at 24 to 28 weeks' gestation with a 50-g glucose load. An abnormal one-hour test result should be followed by confirmatory testing with a three-hour glucose tolerance test. 55 , 56 In contrast, the National Institute for Health and Clinical Excellence has found insufficient evidence to recommend for or against screening for gestational diabetes. 6 In the United States, most women are screened one hour after a 50-g glucose challenge. 57 Selective screening has been shown to miss gestational diabetes in up to one-half of women. 55

HYPERTENSION IN PREGNANCY

Blood pressure is generally monitored at each prenatal visit, and women should be counseled on warning signs of preeclampsia. For women who had chronic or severe hypertension in a previous pregnancy, baseline urine protein and preeclampsia laboratory testing may be helpful. 58 Preeclampsia in a previous pregnancy, chronic hypertension, and low dietary calcium (less than 700 mg) increase the risk of preeclampsia. Calcium supplementation for women with low dietary calcium reduces the risk of preeclampsia by 30% to 50%. 59 Low-dose aspirin from 12 to 36 weeks' gestation reduces preeclampsia by 20% in women with a history of preeclampsia, chronic hypertension, diabetes, autoimmune disease, or renal disease, or in women with current gestational hypertension. 60

PRETERM BIRTH

Preterm birth (before 37 weeks' gestation) is a significant cause of neonatal morbidity and mortality, with more than 500,000 preterm births annually in the United States. 61 Progesterone (preferably weekly injections administered from 16 to 37 weeks' gestation; daily vaginal suppositories are an alternative) reduces preterm birth by approximately 35% in women with a history of spontaneous preterm labor or premature rupture of membranes. 11 , 62 , 63 Cervical cerclage may reduce the risk of preterm birth in women with a previous preterm birth and a short cervix, although the evidence is mixed. 64 Recent studies have shown a significant reduction in preterm birth with vaginal progesterone among women with an asymptomatic short cervix identified on ultrasonography. 65 Smoking cessation and treatment of genital infections may also reduce the risk of preterm birth.

POSTTERM PREGNANCY

A Cochrane review of induction at 41 weeks' gestation versus expectant management to 42 weeks' gestation concluded that perinatal death was less common among women induced at 41 weeks, although it was rare in both groups. 66 The rate of perinatal death was 1.7 per 1,000 in the expectant management group versus 0.5 per 1,000 in the induction group (the number needed to treat with induction to prevent one perinatal death was 410 women). 66 The rate of meconium aspiration syndrome and cesarean delivery were lower with induction. Operative vaginal delivery was slightly more common among women induced at 41 weeks. Women should be counseled about the risks and benefits of both approaches.

Although there is no evidence that prenatal testing decreases perinatal death with postterm pregnancy, the standard of care is twice-weekly nonstress testing and weekly assessment of amniotic fluid volume beginning at 41 weeks' gestation. 6 Physicians should recommend induction of labor for oligohydramnios (amniotic fluid index less than 5 mL or maximum vertical pocket less than 2 cm at term). A nonreactive, nonstress test is usually followed by a biophysical profile, a contraction stress test, or umbilical artery Doppler. 67 If these tests are not reassuring after 41 weeks' gestation, physicians should recommend induction of labor. 9

Data Sources : We identified guidelines/studies from PubMed, Cochrane Database of Systematic Reviews, Institute for Clinical Systems Improvement, USPSTF, ACOG, Society of Obstetricians and Gynaecologists of Canada, and Royal College of Obstetricians and Gynaecologists. We searched prenatal care with randomized controlled trial, evidence-based review, meta-analysis, and systematic review. We also searched pregnancy with physical exam, ultrasound, dating, alloimmunization, anemia, genetic testing, trisomy 21, and thyroid. Search dates: November 1, 2011, and December 2, 2013.

Guyer B. Medicaid and prenatal care. JAMA. 1990;264(17):2264-2265.

Hanson L, VandeVusse L, Roberts J, et al. A critical appraisal of guidelines for antenatal care. J Midwifery Womens Health. 2009;54(6):458-468.

Maupin R, Lyman R, Fatsis J, et al. Characteristics of women who deliver with no prenatal care. J Matern Fetal Neonatal Med. 2004;16(1):45-50.

Vintzileos AM, Ananth CV, Smulian JC, et al. The impact of prenatal care in the United States on preterm births in the presence and absence of antenatal high-risk conditions. Am J Obstet Gynecol. 2002;187(5):1254-1257.

Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2010(10):CD000934.

National Institute for Health and Clinical Excellence. Antenatal care: routine care for the healthy pregnant woman. Clinical guideline, CG62. March 2008. http://www.nice.org.uk/CG62 . Accessed August 8, 2012.

Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database Syst Rev. 2000(2):CD000062.

Neilson JP. Symphysis-fundal height measurement in pregnancy. Cochrane Database Syst Rev. 2000(2):CD000944.

Ratcliffe SD, et al. Family Medicine Obstetrics . 3rd ed. Philadelphia, Pa.: Mosby Elsevier; 2008.

Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: part I. Am Fam Physician. 2005;71(7):1307-1316.

Institute for Clinical Systems Improvement. Health care guidelines. Routine prenatal care. July 2012. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_womens_health_guidelines/prenatal/ . Accessed August 8, 2012.

American College of Obstetricians and Gynecologists. Cervical cytology screening. Obstet Gynecol. 2009;114(6):1409-1420.

Lee SJ, Thomas J. Antenatal breast examination for promoting breast-feeding. Cochrane Database Syst Rev. 2008(3):CD006064.

Thornton YS, Smarkola C, Kopacz SM, et al. Perinatal outcomes in nutritionally monitored obese pregnant women. J Natl Med Assoc. 2009;101(6):569-577.

Michalowicz BS, et al. Treatment of periodontal disease and the risk of preterm birth. N Engl J Med. 2006;355(18):1885-1894.

Wilson RD, Davies G, Désilets V, et al.; Genetics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. The use of folic acid for the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can. 2003;25(11):959-973.

Duong HT, Shahrukh Hashmi S, Ramadhani T, et al. Maternal use of hot tub and major structural birth defects. Birth Defects Res A Clin Mol Teratol. 2011;91(9):836-841.

Lumley J, Chamberlain C, Dowswell T, et al. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2009(3):CD001055.

Chard T. Pregnancy tests: a review. Hum Reprod. 1992;7(5):701-710.

Demianczuk NN, Van Den Hof MC, Farquharson D, et al.; Diagnostic Imaging Committee of the Executive and Council of the Society of Obstetricians and Gynecologists of Canada. The use of first trimester ultrasound. J Obstet Gynaecol Can. 2003;25(10):864-875.

Whitworth M, Bricker L, Neilson JP, et al. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev. 2010(4):CD007058.

Ewigman BG, Crane JP, Frigoletto FD, et al. Effect of prenatal ultrasound screening on perinatal outcome. N Engl J Med. 1993;329(12):821-827.

American College of Obstetricians and Gynecologists. Ultrasonography in pregnancy. Obstet Gynecol. 2009;113(2 pt 1):451-461.

Crowther CA, Keirse MJ. Anti-D administration in pregnancy for preventing rhesus alloimmunisation. Cochrane Database Syst Rev. 2000(2):CD000020.

American College of Obstetricians and Gynecologists. Management of alloimmunization during pregnancy. Obstet Gynecol. 2006;108(2):457-464.

American College of Obstetricians and Gynecologists. Anemia in pregnancy. Obstet Gynecol. 2008;112(1):201-207.

Routine iron supplementation during pregnancy. Review article. U.S. Preventive Services Task Force. JAMA. 1993;270(23):2848-2854.

Haider BA, et al. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev. 2006(4):CD004905.

Chitayat D, Langlois S, Wilson RD Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada; Prenatal Diagnosis Committee of the Canadian College of Medical Geneticists. Prenatal screening for fetal aneuploidy in singleton pregnancies. J Obstet Gynaecol Can. 2011;33(7):736-750.

Smith DK, Shaw RW, Marteau TM. Informed consent to undergo serum screening for Down's syndrome: the gap between policy and practice. BMJ. 1994;309(6957):776.

Verweij EJ, van den Oever JM, de Boer MA, et al. Diagnostic accuracy of noninvasive detection of fetal trisomy 21 in maternal blood. Fetal Diagn Ther. 2012;31(2):81-86.

Casey BM, Leveno KJ. Thyroid disease in pregnancy. Obstet Gynecol. 2006;108(5):1283-1292.

Surks MI, Ortiz E, Daniels GH, et al. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA. 2004;291(2):228-238.

Lazarus JH, Bestwick JP, Channon S, et al. Antenatal thyroid screening and childhood cognitive function [published correction appears in N Engl J Med . 2012;366(17):1650]. N Engl J Med. 2012;366(6):493-501.

McDonald HM, Brocklehurst P, Gordon A. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev. 2007(1):CD000262.

Royal College of Obstetricians and Gynaecologists. Chickenpox in pregnancy (green-top 13). January 9, 2007. http://www.rcog.org.uk/womens-health/clinical-guidance/chickenpox-pregnancy-green-top-13 . Accessed August 8, 2012.

Manual for the Surveillance of Vaccine-Preventable Diseases . 5th ed. Atlanta, Ga.: Centers for Disease Control and Prevention; 2012.

Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2007(2):CD000490.

Centers for Disease Control and Prevention. Guidelines for vaccinating pregnant women. http://www.cdc.gov/vaccines/pubs/preg-guide.htm . Accessed January 9, 2014.

Prevention and control of influenza. MMWR Recomm Rep. 1999;48(RR-4):1-28.

Verani JR, McGee L, Schrag SJ Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Prevention of perinatal group B streptococcal disease—revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010;59(RR-10):1-36.

Workowski KA, Berman S Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010 [published correction appears in MMWR Recomm Rep . 2011;60(1):18]. MMWR Recomm Rep. 2010;59(RR-12):1-110.

Brocklehurst P, Rooney G. Interventions for treating genital Chlamydia trachomatis infection in pregnancy. Cochrane Database Syst Rev. 2000(2):CD000054.

U.S. Preventive Services Task Forces. Screening for chlamydial infection. June 2007. http://www.uspreventiveservicestaskforce.org/uspstf/uspschlm.htm . Accessed October 10, 2012.

American College of Obstetricians and Gynecologists. Clinical management guidelines for obstetrician-gynecologists. No. 82 June 2007. Management of herpes in pregnancy. Obstet Gynecol. 2007;109(6):1489-1498.

Hollier LM, Hill J, Sheffield JS, et al. State laws regarding prenatal syphilis screening in the United States. Am J Obstet Gynecol. 2003;189(4):1178-1183.

Yinon Y, Farine D, Yudin MH, et al.; Society of Obstetricians and Gynaecologists of Canada. Cytomegalovirus infection in pregnancy. J Obstet Gynaecol Can. 2010;32(4):348-354.

Crane J Society of Obstetricians and Gynaecologists of Canada. Parvovirus B19 infection in pregnancy. J Obstet Gynaecol Can. 2002;24(9):727-743.

Plichta SB. Intimate partner violence and physical health consequences. J Interpers Violence. 2004;19(11):1296-1323.

U.S. Preventive Services Task Force. Screening for intimate partner violence and abuse of elderly and vulnerable adults. January 2013. http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm . Accessed January 9, 2014.

Zolotor AJ, Theodore AD, Coyne-Beasley T, et al. Intimate partner violence and child maltreatment. Brief Treat Crisis Interv. 2007;7(4):305-321.

American College of Obstetricians and Gynecologists. Screening for depression during and after pregnancy. Obstet Gynecol. 2010;115(2 pt 1):394-395.

American College of Obstetricians and Gynecologists. Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111(4):1001-1020.

Metzger BE, Lowe LP, Dyer AR, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991-2002.

American College of Obstetricians and Gynecologists. Gestational diabetes mellitus. August 2013. http://www.mfmsm.com/media_pages/MFM-Gestational-Diabetes-Mellitus.pdf . Accessed December 2, 2013.

Screening for gestational diabetes mellitus: U.S. Preventive Services Task Force recommendation statement [published ahead of print January 14, 2014]. Ann Intern Med. . Accessed March 5, 2014. http://annals.org/article.aspx?articleid=1813285&resultClick=3

Wilkins-Haug L, Horton JA, Cruess DF, et al. Antepartum screening in the office-based practice. Obstet Gynecol. 1996;88(4 pt 1):483-489.

Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-1131.

Hofmeyr GJ, Lawrie TA, Atallah AN, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2010(8):CD001059.

Duley L, Henderson-Smart DJ, Meher S, et al. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007(2):CD004659.

Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2007. Natl Vital Stat Rep. 2009;57(12):1-23.

Dodd JM, Flenady V, Cincotta R, et al. Prenatal administration of progesterone for preventing preterm birth. Cochrane Database Syst Rev. 2006(1):CD004947.

Petrini JR, Callaghan WM, Klebanoff M, et al. Estimated effect of 17 alpha-hydroxyprogesterone caproate on preterm birth in the United States. Obstet Gynecol. 2005;105(2):267-272.

Berghella V, Odibo AO, To MS, et al. Cerclage for short cervix on ultrasonography. Obstet Gynecol. 2005;106(1):181-189.

Romero R, Nicolaides K, Conde-Agudelo A, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity. Am J Obstet Gynecol. 2012;206(2):124.e1-19.

Gülmezoglu AM, Crowther CA, Middleton P, et al. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2012(6):CD004945.

American College of Obstetricians and Gynecologists. Management of postterm pregnancy. Obstet Gynecol. 2004;104(3):639-646.

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Your first prenatal appointment: What to expect

The first prenatal visit is one of the longest appointments a woman will have during pregnancy, with several tests and a lot of important information conveyed..

During pregnancy, you need regular prenatal visits to keep yourself and the pregnancy healthy. These visits are called prenatal care appointments. In these visits, you might meet with an OB/Gyn, a midwife or a nurse practitioner.

During pregnancy, you'll meet with your prenatal care provider every four weeks until you are about 28 weeks (7 months) pregnant. After that, you'll come every two weeks. Then, in your last month of pregnancy, we'll want to see you weekly.

Your first appointment will likely be the longest of the many prenatal visits to come. At that visit, we will discuss your overall health, answer your first round of questions and help you prepare for the next nine months.

Most women make an appointment after they get a positive result from a home pregnancy test. Often, this is one or two weeks after a missed period. Call us at 505-272-2245 , and we will schedule your first prenatal appointment between six and eight weeks of pregnancy.

What to Expect

Confirming the pregnancy.

Sometimes, home pregnancy tests give false positives—it says you are pregnant, but you aren't. And unfortunately, approximately one in four pregnancies ends in miscarriage , often early in pregnancy. Before we do any other tests, we'll first confirm your pregnancy with a urine test and blood draw.

Estimating Your Due Date

We’ll also ask about your periods:

How old you were when they started
How regular they are
When your last period started

This information helps us estimate your due date—when we expect the baby to come. The due date is approximately nine months from the first day of your last period.

We’ll also discuss whether you want to continue with the pregnancy. Nearly half of all pregnancies in the U.S. are unplanned. It’s OK to not immediately know how you feel about being pregnant, or what you want to do. At your first prenatal visit, we can talk you through your options . We will support you in whatever you decide.

Personal and Family Medical History

Be prepared to discuss your personal and family medical history. This information helps us determine whether the embryo might be at risk for health problems.

Some of the topics we'll discuss include:

Alcohol, tobacco and caffeine use
Chronic conditions, such as diabetes and high blood pressure
Exposure to potentially toxic substances
Genetic disorders
Medications, including supplements and over-the-counter drugs
Past surgeries
Pregnancy complications
Travel to countries where infectious diseases—such as Zika virus or malaria—are common

At your first visit, we'll also discuss social concerns, such as whether you feel safe at home and at work. Your employer is required to give you accommodations if your job is unsafe for pregnancy. If you don’t feel safe, we can discuss options to manage that situation.

You’ll also get a battery of tests to examine the health of you and your baby. These can include blood and urine tests to look for:

Blood type and Rh status to determine if you are Rh negative, which can affect the pregnancy
Glucose levels
Immunity to measles and chickenpox
Infections such as rubella, hepatitis B and C, syphilis and HIV
Urinary tract infections, gonorrhea and chlamydia

Depending on your age and health history, your may also be offered an optional blood test called noninvasive prenatal testing (NIPT) . This screening can be done as early as nine weeks and can determine whether the embryo may be at risk for genetic conditions such as:

Down syndrome (trisomy 21)
Edward’s syndrome (trisomy 18)
Patau syndrome (trisomy 13)

Physical Exam

We’ll check your vitals such as blood pressure and calculate your body mass index to determine how much weight you should gain during pregnancy. We’ll also do a head-to-toe physical exam that may include a breast exam, pelvic exam and screenings of your heart, lungs and thyroid. If you’re due for a Pap smear to check for cervical cancer, we can also do that test at the first visit. We may also try to find out how big your uterus is and if this corresponds to how many weeks pregnant you think you are. We can usually hear fetal heart tones with a doppler after 10 weeks.

Getting an ultrasound at your first prenatal appointment is not required. But we do them more often than not. The ultrasound helps narrow down your due date and confirms that the pregnancy is in the uterus. We also may be able to hear the heartbeat at this time and see if you’re having than one baby.

However, if you’re hoping to learn whether you’re having a boy or girl, you'll have to wait a bit longer! The baby won't be that apparent on ultrasound until approximately 20 weeks.

Education and Resources

Education is a big part of prenatal care. All patients who deliver at UNM Hospital get access to:

Managing pregnancy symptoms: Some early pregnancy body changes are weird, but normal. These include tender, swollen breasts, fatigue or nausea and vomiting. We can discuss how to manage these symptoms and when to see your doctor.
Prenatal vitamins: It’s important to take prenatal vitamins with folic acid to prevent neural tube defects and walk you through some foods to avoid—such as alcohol, unpasteurized cheeses, deli meats, and raw fish. We also can suggest exercises that are safe to do during pregnancy .
Drug and alcohol support: During pregnancy, it's important to quit drinking, smoking and using drugs. If you need help to quit, we can recommend pregnancy-safe medications and options. For example, our Milagro Clinic is designed specifically to give pregnant patients safe, respectful addiction care.
Prenatal classes: From new parent classes to childbirth classes , we offer a range of in-person and Zoom classes to help you prepare for parenting.
Financial assistance: There are financial programs at UNM Hospital and in the community to help families with no or limited health insurance.
Home visits: We can connect you to programs for first time moms that offer home visits at no charge to families with new babies. At these visits, we'll answer your questions and help troubleshoot feeding concerns.

Your first prenatal appointment might seem a bit overwhelming. But we are here for you. We will give you all the information you need to have a healthy pregnancy. And we’ll be by your side, all the way.

Get Expert OB/Gyn Care

Visit the UNM Women's Health site to browse our services. Learn More .

Contact for Members of the Press

Chris Ramirez (505) 313-3429 [email protected]

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Prenatal Blood Tests on Your First Visit

First visit prenatal tests

Most people associate the word "pregnancy test" with an initial test to check if you are pregnant or not, either a urine or a blood test. However, there are many more tests done during pregnancy, once you know that you are pregnant. As part of routine prenatal care, certain blood and other tests are usually done, some routinely, others based on your history. These tests are done to detect certain conditions and to decide whether you need additional tests or whether treatment is indicated. For example, some tests detect sexually transmitted diseases that could affect the fetus and baby if untreated. Below is a list of tests done during pregnancy:

Urine Pregnancy Test - Checks for the presence of the pregnancy hormone hCG in your urine
Blood Pregnancy Test - Checks for the presence of the pregnancy hormone hCG in your blood
Complete Red Cell Blood Count (CBC) - Checks for anemia, blood diseases, platelet count
Blood Type - A mother is either O, A, B, or AB
Rh-Factor - The test shows that the Rh-factor is either positive or negative. A mother's negative Rh Factor may be a problem if she develops antibodies against the baby's red cells
Antibody (Coombs test) - Certain antibodies like Rh (Rhesus) or Kell antibodies can harm the fetus
Hemoglobin electrophoresis - Tests for abnormal hemoglobins associated with genetic conditions (eg sickle cell, thalassemia)
Hepatitis B antigen - If there is Hepatitis B antigen present then the baby can become infected at birth. If you have HepB antibody then you are immune. Getting immunization against HepB prevents an infection.
Hepatitis C screening - This is the newest recommendation by the CDC.
Syphilis screen - Syphilis is a sexually transmitted disease that can harm the mother and can infect the fetus. It can be treated with antibiotics to prevent fetal and newborn infection
HIV screen - HIV can be treated in pregnancy to prevent the baby from becoming infected
Rubella (German measles) - A positive test shows that the mother is immune against rubella
Varicella (Chickenpox) antibody - A positive test shows immunity against varicella unless you recently had chickenpox in which case it shows a recent infection.
Genetic screen - Testing for Cystic Fibrosis is done routinely. Other tests are done for patients in certain ethnic groups
Rubeola (measles) antibody - A positive test shows immunity
Fifth Disease (parvovirus antibody ) (optional) - A positive test shows immunity
Toxoplasma antibody (optional) - A positive toxoplasmosis test shows either partial immunity or a new infection. A new infection is more likely if the toxoplasma IgM is also positive in addition to the toxoplasma IGG
Cytomegalovirus (CMV) antibody (optional) - A positive test shows partial immunity
Urine test for protein, ketones, leukocytes, urine culture - Tests are usually done by dipping a test strip into the urine. In addition, urine is also often sent to the laboratory for culture for bacteria. Treatment is indicated if tests are abnormal
Pap (Papanicolaou) cervix smear - An abnormal pap smear result needs to be further evaluated
Cervix or urine screen for Gonorrhea and Chlamydia - Gonorrhea and Chlamydia infections can be treated with antibiotics
Tuberculosis (PPD) screen (if at risk) - Tuberculosis testing and treatment is important
Early first visit ultrasound - Determines pregnancy viability; checks position and location of pregnancy; measures gestational age and determines the due date
Cell-free DNA test - Done from mother's blood as early as 9 weeks to screen for chromosomal anomalies in the fetus

Read More: What Happens at Your First Prenatal Appointment? Laboratory Values During Pregnancy

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pregnant-woman-doctor-stethoscope-first-prenatal-visit | American Pregnancy Association

Your First Prenatal Visit

If you did not meet with your health care provider before you were pregnant, your first prenatal visit will generally be around 8 weeks after your LMP (last menstrual period ). If this applies to you, you should schedule a prenatal visit as soon as you know you are pregnant!

Even if you are not a first-time mother, prenatal visits are still important since every pregnancy is different. This initial visit will probably be one of the longest. It will be helpful if you arrive prepared with vital dates and information. This is also a good opportunity to bring a list of questions that you and your partner have about your pregnancy, prenatal care, and birth options.

What to Expect at Your First Pregnancy Appointment

Your doctor will ask for your medical history, including:.

Medical and/or psychosocial problems
Blood pressure, height, and weight
Breast and cervical exam
Date of your last menstrual period (an accurate LMP is helpful when determining gestational age and due date)
Birth control methods
History of abortions and/or miscarriages
Hospitalizations
Medications you are taking
Medication allergies
Your family’s medical history

Your healthcare provider will also perform a physical exam which will include a pap smear , cervical cultures, and possibly an ultrasound if there is a question about how far along you are or if you are experiencing any bleeding or cramping .

Blood will be drawn and several laboratory tests will also be done, including:

Hemoglobin/ hematocrit
Rh Factor and blood type (if Rh negative, rescreen at 26-28 weeks)
Rubella screen
Varicella or history of chickenpox, rubella, and hepatitis vaccine
Cystic Fibrosis screen
Hepatitis B surface antigen
Tay Sach’s screen
Sickle Cell prep screen
Hemoglobin levels
Hematocrit levels
Specific tests depending on the patient, such as testing for tuberculosis and Hepatitis C

Your healthcare provider will probably want to discuss:

Recommendations concerning dental care , cats, raw meat, fish, and gardening
Fevers and medications
Environmental hazards
Travel limitations
Miscarriage precautions
Prenatal vitamins , supplements, herbs
Diet , exercise , nutrition , weight gain
Physician/ midwife rotation in the office

Possible questions to ask your provider during your prenatal appointment:

Is there a nurse line that I can call if I have questions?
If I experience bleeding or cramping, do I call you or your nurse?
What do you consider an emergency?
Will I need to change my habits regarding sex, exercise, nutrition?
When will my next prenatal visit be scheduled?
What type of testing do you recommend and when are they to be done? (In case you want to do research the tests to decide if you want them or not.)

If you have not yet discussed labor and delivery issues with your doctor, this is a good time. This helps reduce the chance of surprises when labor arrives. Some questions to ask include:

What are your thoughts about natural childbirth ?
What situations would warrant a Cesarean ?
What situations would warrant an episiotomy ?
How long past my expected due date will I be allowed to go before intervening?
What is your policy on labor induction?

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Pregnancy is a transformative and exciting journey that brings profound physical and emotional changes for expectant mothers. As nursing professionals, understanding and addressing these changes is essential in providing comprehensive care during pregnancy. The first prenatal visit holds immense significance as it sets the foundation for a successful pregnancy journey, ensuring optimal maternal and fetal well-being through early detection, education, and tailored care plans.

This article aims to serve as a comprehensive nursing guide, focusing on the common pregnancy changes experienced by women and the critical aspects of the first prenatal visit. This serves as a valuable resource, equipping nursing professionals with the knowledge and skills necessary to provide comprehensive care, support, and education to women embarking on the beautiful journey of pregnancy.

Presumptive signs, probable signs, positive signs, reproductive system changes, breast changes, integumentary system, respiratory system, cardiovascular system, gastrointestinal system, urinary system, skeletal system, endocrine system, mood swings, changes in sexual desire, introversion/extroversion, social changes, cultural changes, family changes, individual changes, first trimester: accepting the pregnancy, second trimester: accepting the baby, third trimester: preparing for the baby, breast tenderness, palmar erythema, constipation, nausea, vomiting, pyrosis, muscle cramps, hypotension, varicosities, hemorrhoids, heart palpitations, frequent urination, ankle edema, braxton hicks contraction, recommended weight gain, energy needs, protein needs, vitamin needs, mineral needs, fluid needs, fiber needs, healthy signs of good nutrition, health history, demographic data, chief concern, history of past illnesses, history of family illnesses, social profile, gynecologic history, obstetric history, systemic assessment.

Papanicolaou Smear (Pap smear)

Blood Studies

Glucose tolerance test, ultrasonography, preconception classes, expectant parenting classes, sibling education classes, breastfeeding classes, preparation for childbirth classes, the bradley method, the dick-read method, the lamaze method, the appropriate setting, the birth attendant and support person, hospital birth, alternative birthing centers, physiological changes in pregnancy.

A woman certainly undergoes a lot of changes during pregnancy. Some gain changes permanently, others have changes that are very subtle. These changes, however, are welcomed by mothers with open arms because they are signs that a new life is being formed inside of her.

The Diagnosis of Pregnancy

Before a pregnancy is confirmed, the woman might see small and big changes in her body that could help in determining if she is already pregnant.

Presumptive signs are signs that are least indicative of a pregnancy. These changes can only be felt by the woman but cannot be documented by the healthcare provider.

Breast changes (swollen), nausea and vomiting , amenorrhea, frequent urination, fatigue , uterine enlargement, quickening , linea nigra, melasma, and striae gravidarum are the presumptive signs of pregnancy.
However, these signs may also denote other conditions that the body is undergoing.

Probable signs of pregnancy are objective and can be seen primarily by the healthcare provider. These can be taken through laboratory tests and home pregnancy tests by detect the presence of human chorionic gonadotropin in the blood or in the urine.

Chadwick’s sign or a change in the color of the vagina from pink to violet is a probable sign of pregnancy.
Goodell’s sign is a probable sign that depicts a softening of the cervix.
Hegar’s sign is the softening of the lower uterine segment.
Ballottement is described as the rise of the fetus felt through the abdominal wall when the uterine segment is tapped on a bimanual examination.
An evidence of a gestational sac found during ultrasound is another probable sign.
Braxton-Hicks contractions are periodic uterine tightening and contractions.
The fetal outline can also be now palpated by the examiner through the abdomen.

There are only three positive signs of pregnancy that are documented by the health care providers.

Evidence of a fetal outline on ultrasound.
With the use of a Doppler, an audible fetal heart rate is another positive sign.
The last is fetal movement felt by the healthcare provider.

The system that will greatly feel the changes is the reproductive system. It includes the ovaries, uterus, and vagina.

On the first trimester in the ovaries, the corpus luteum starts to become active. By the second trimester, it begins to fade until the third trimester where it has already disappeared.
The uterus increases in growth starting from the first trimester. On the second trimester, the placenta is forming estrogen and progesterone.
The vagina undergoes changes during the first trimester wherein a whitish discharge is present. From the second until the third trimester, the whitish discharge increases in amount.
Amenorrhea also occurs, or the absence of menstruation .
The cervix undergoes a more vascular and edematous appearance owing to the increased level of estrogen.
Breast changes start from the first trimester as the woman feels tenderness and fullness of her breasts.
As the pregnancy progresses, the breast size increases a size or two, as the mammary alveoli and fat deposits increase in size.
The areola of the nipples become darker and its diameter increases.
The vascularity of the breast also increases, as evidenced by the prominent blue veins over the surface.
The Montgomery’s tubercles or the sebaceous glands of the areola protrudes and enlarges.

Systemic Changes

After the changes that occurred mainly in the reproductive system of a pregnant woman, systemic changes will also start to occur in different body systems.

The stretching of the abdomen causes rupture of the small segments of the connective layer of the skin.
Striae gravidarum or pinkish to reddish marks on the sides of the abdominal wall are the result of the rupture.
Linea nigra is a narrow, brown line that runs from the symphysis pubis to the umbilicus and separates the abdomen into right and left hemispheres.
Melasma or chloasma (mask of pregnancy) refers to the darkened areas on the cheeks or the nose that may appear during pregnancy.
Telangiectasis is red, branching spots that can be seen on the thighs. It is also called as vascular spiders.
Palmar erythema also occurs because of the increase in the estrogen level of the pregnant woman.
A pregnant woman usually experiences stuffiness or marked congestion because of the increasing estrogen levels.
Shortness of breath is also a common discomfort of pregnancy as the pregnant uterus pushes the diaphragm upward.
The total oxygen consumption of a pregnant woman increases by 20%.
The blood pressure of the pregnant woman decreases in the second trimester and then returns to its prepregnancy level on the third trimester.
The cardiac output increases 25% to 50%.
Plasma volume also increases up to 3600 mL, marking the condition called pseudoanemia early in the pregnancy.
Heart rate also increases to 80 to 90 beats per minute.
The blood volume increases up to 5,250 mL during pregnancy.
Nausea and vomiting is one of the first signs of pregnancy that a woman feels.
Slower intestinal peristalsis occurs during the second trimester of the pregnancy which causes heartburn, flatulence, and constipation .
Hemorrhoids also occur from the increased pressure of the uterus on the veins in the lower extremities.
The total body water of a pregnant woman increases up to 7.5 L for a more effective placental exchange.
Even when the woman has an increased urine output, her potassium levels are still adequate due to progesterone, which is potassium -sparing.
The bladder capacity increases to accommodate 1,000 mL of urine during pregnancy.
On the first trimester, the frequency of urination already increases. By the last two weeks of pregnancy it reaches up to 10 to 12 times per day.
By the 32 nd week of pregnancy, the symphysis pubis widens for 3 to 4 mm.
The center of gravity of a pregnant woman changes, and to make up for it she tends to stand straighter and taller than usual and with the abdomen forward and the shoulders thrown back, the ‘pride of pregnancy’ or commonly ‘lordosis’ occurs.
A slight enlargement in the thyroid and parathyroid gland increases the basal metabolic rate of a pregnant woman and for better consumption of calcium and vitamin D.
Thyroid hormone production increases.
The insulin produced from the pancreas decreases early in the pregnancy, thereby increasing glucose available for the fetus.
Increase in insulin occurs in the first trimester because estrogen, progesterone and HPL have insulin antagonistic properties.
FSH and LH decreases causing anovulation .
As the breasts are prepared for lactation, prolactin increases in production.
The increase in melanocyte-stimulating hormones causes increase in skin pigment.
The human growth hormone increase to aid the fetus in growing.
Estrogen and progesterone aids in uterine and breast enlargement.
Human placental lactogen increases glucose levels to supplement the growing fetus.
Relaxin increases to soften the cervix and collagen of joints.

The changes in the physiologic status of a pregnant woman are just one of the many phases of changes that occur during pregnancy. Most of these are normal, but when the pregnant woman experiences an excessive manifestation of these signs, it would be best to consult your healthcare provider.

Psychological Changes in Pregnancy

The various changes that a woman undergoes during pregnancy entirely sweep the entirety of the human body. Almost every aspect is altered, hormones get together to create a whole new modifications in the mind, the body, and the emotions. Psychological aspects would also be given a new perspective as it also alters together with the rest of the woman’s body.

How a Woman Responds to Pregnancy

Mood swings, grief , changes in sexual desires, and stress are only some of the psychological changes that a pregnant woman experiences. The couple might misinterpret these changes, so health education must be integrated in the care of the pregnant woman.

Grief may arise from the realization that one’s roles would be changed permanently.
A pregnant woman would be weaned off her role as a dependent daughter, or as a happy-go-lucky girl, or a friend who is always available.
Even the partner would have to leave the roles or the life he has been accustomed to as a man without a child to support.
Also known as emotional lability, this psychological reaction can be caused by two factors: hormonal changes or narcissism.
The comments that she had brushed off in her nonpregnant state can now touch a nerve or hurt her.
Crying is a common manifestation of mood swings, during and even after the pregnancy.
Women who are on the first trimester of pregnancy experience a decrease in libido mainly because of breast tenderness, nausea, and fatigue.
On the second trimester, sexual libido may rise because of increased blood flow to the pelvic area that supplies the placenta.
The third trimester might bring an increase or decrease in sexual libido due to an increase in the abdominal size or difficulty in finding a comfortable position.
Estrogen increase may also affect sexual libido as it may bring a loss of desire.
The couple must be informed that these changes are normal to avoid misunderstanding the woman’s attitude.
Pregnancy is a major change in roles that could cause stress.
The stress that a pregnant woman feels might affect her ability to decide.
The discomforts that she may feel could also add up to the stress she is experiencing.
Assess whether the woman is in an abusive relationship as it may contribute further to the stress.
Introversion refers to someone who focuses entirely on her own body and a common manifestation during pregnancy.
Some pregnant women also manifest extroversion, or acting more active, healthier and more outgoing than before their pregnancy.
Extroversion commonly happens to women who had a hard time conceiving and finally hit jackpot.
In the past, a pregnant woman is isolated from her family starting from visiting for prenatal consultation until the day of birth.
She is isolated from her family and the baby a week after birth.
Today, having a support system for pregnant women is highly encouraged, like bringing along someone to accompany her during prenatal visits and allowing the husband to be with the wife during birth if he chooses to.
Opinions on teenage pregnancy, late pregnancies, and having the same sex parents are now widely accepted compared to being taboos in the past.
A pregnant woman’s culture and beliefs may also greatly affect the course of her pregnancy.
Assess if the woman and her partner have particular beliefs that might affect the way the take care of the pregnancy so you can integrate them in your plan of care.
Despite the modern ages, there are still groups who firmly believe in their culture’s explanations about birth complications and the health care providers must respect this.
Myths that surround the pregnancy should always be respected, but the couple should be educated properly regarding what could be dangerous for the fetus’ health.
The environment where the woman grew influences the way she would perceive her pregnancy.
Family culture and beliefs also affect a woman’s perception of pregnancy.
If she is loved as a child, she would have an easy time accepting her pregnancy compared to women who were neglected by her family during childhood.
A woman who has been told of disturbing stories about giving birth and pregnancy would view her own in a negative light, while those who grew with beautiful birth stories would more likely be excited for their pregnancy.
A positive attitude would only result from a positive outcome and influence from the woman’s own family.
Becoming a new mother is never an easy transition. The woman must first be able to cope with stress effectively, as this is a major concern during pregnancy.
She needs to have the ability to adapt effectively to any situation, especially if the pregnancy is her first because there might be a lot of new situations that would arise.
Her ability to cope with a major change and manage her temper would be put to a test during motherhood.
The woman’s relationship with her partner also affects her ability to accept her pregnancy easily.
If she feels secure with her relationship with the father of her child, she would have an easier time accepting her pregnancy as opposed to an unstable relationship where she feels insecure and may doubt the decision of keeping the pregnancy.
A woman who feels that the pregnancy may rob her of her looks, her freedom, a promotion, or her youth would need to have a strong support system so she could express her feelings and unburden her chest.
The father’s acceptance of the pregnancy also influences the woman’s ability to accept the marriage.
Utmost support from her husband would be very meaningful for the woman especially during birth.

The Psychological Tasks of Pregnancy

Both the woman and her husband walk through a tangle of emotions during pregnancy. Accepting that a new life would be born out of your blood is not as easy as others may think. There are several stages that both should undergo, the psychological way.

The shock of learning about a new pregnancy is sometimes too heavy for a couple, so it is just proper for the both of them to spend some time recovering from this major life-altering situation and avoid overwhelming themselves at first.
One of the most common reactions of a couple who would be having a baby for the first time is ambivalence, or feeling both pleased and unhappy about the pregnancy.
The woman and her partner will start to merge into the role of novice parents as second trimester closes in.
Emotions such as narcissism and introversion are commonly present at this stage.
Role playing and increased dreaming are activities that help the couple embrace their roles as parents.
At this stage, the woman and her partner must start to concentrate on what it will feel like to be parents.
The couple starts to grow impatient as birth nears.
Preparations for the baby, both small and big, takes place during this stage.
The baby’s clothing and sleeping arrangements are set and the couple is excited for his arrival.

The transition of a woman from the start until the end of the pregnancy is a big turning point for her and the people who surround her. Every single one of them must be prepared physically, mentally and emotionally because pregnancy is also considered a crisis in life; something that could turn your world upside down.

Discomforts of Pregnancy

Pregnancy ultimately builds up a woman. It is the pinnacle of life wherein women become more than just women; they become mothers. The journey of pregnancy is also a tough one but is meaningful and wonderful. The discomforts a woman would undergo are just bumps along the road of fulfillment once she has delivered her child.

Discomforts during the First Trimester

There are a number of discomforts that can be felt during the first trimester. This is the time when the body is just starting to adjust to the pregnancy, and hormones are still in chaos. The woman must be educated on how to ease these discomforts to help her adjust slowly.

Breast tenderness is one of the first symptoms that the woman would notice in early pregnancy. The tenderness may vary between women; some hardly notice the sensation at all.

Advise to wear a bra with a wide shoulder strap. The support it gives helps ease the tenderness.
Dress warmly and avoid cold. She should also dress warmly as exposure to cold increases the tenderness.
Get examined. Women who experience intense pain should have to examine the presence of nipple fissures or breast abscess to rule out these conditions.

Palmar erythema is the constant itching and redness of the palms but is not considered an allergy . Increased estrogen levels possibly cause the pruritus.

Palmar erythema. Image via thebileflow.wordpress.com

No it’s not an allergy . Educate the woman that she has not developed an allergy, and this is normal during pregnancy.
Calamine lotion to the rescue. To soothe the itchiness, calamine lotion can be applied.
Disappears naturally. Palmar erythema would naturally disappear once the body has adjusted to the increased estrogen levels.

Constipation is caused by slow peristalsis due to the pressure from the growing uterus.

Increase fiber in the diet. Encourage the woman to move her bowels regularly and increase the fiber in her diet.
Drink water. Advise her to drink at least 8 to 10 glasses of water every day.
Iron supplements. Educate her that iron supplements can cause constipation but need not be stopped because it helps build up fetal iron stores.
Don’t use mineral oil. The use of mineral oil to relieve constipation is not advisable because it absorbs the fat-soluble vitamins A, D, K, and E.
Don’t use enemas. Enemas are also prohibited as it may initiate labor .
So as OTC laxatives. Over-the-counter laxatives are also contraindicated unless prescribed.
Avoid gas-forming foods. Advise the woman to avoid gas-forming food to prevent excessive flatulence.

Nausea and vomiting are also one of the earliest symptoms of pregnancy. Pyrosis or heartburn typically occurs when the woman ate a large meal.

Small frequent feedings. Advise the woman to take small, frequent meals and avoid greasy foods.
Upright position after. Encourage her to keep in an upright position after meals to avoid reflux.

Pregnant women experience fatigue mostly in early pregnancy because of increased metabolic requirements .

Rest and sleep . Advise her to increase the amount of rest and sleep and to continue with her normal nutrition intake.
Take short breaks. For women who still work, advise her to take short breaks, especially if her work involves being up and about the whole day.

Muscle cramps are caused by decreased serum calcium levels, increased phosphorus levels, or interference in the circulation.

Lie down. Advise the woman that when this happens, she should lie on her back and extend the affected leg while she keeps her knee straight and dorsiflexes the foot.
Magnesium citrate or aluminum hydroxide gel. Magnesium citrate or aluminum hydroxide gel is prescribed to women who have frequent and unrelieved muscle cramps.
Raise those feet. The woman should elevate her lower extremities frequently to promote circulation.

When the woman lies on her back and the uterus presses upon the vena cava, supine hypotension might occur, impairing blood return to the heart.

Sleep sideways. Advise woman to rest or sleep on her side, not on her back.
Rise slowly. Encourage her to rise slowly and dangle feet over the bed for a few minutes; avoid standing for extended periods.

Varicosities are tortuous veins caused by the pressure of the uterus to veins at the lower extremities.

Raise legs. Advise the woman to rest in Sim’s position or on the back with the legs raised against the wall.
Don’t cross legs. Discourage sitting with legs crossed or knees bent and the use of constrictive knee-high hose or garters.
Support stockings do wonders. The use of elastic support stockings is advised to relieve varicosities.
Exercise and walk. Exercise is also effective through taking walk breaks from chores or from standing or sitting for too long.
Vitamin C helps. Vitamin C is also recommended to reduce varicosities for the formation of blood vessel collagen and endothelium.

Hemorrhoids are varicosities of the rectal veins that occur because of the pressure of the veins from the weight of the uterus.

Evacuate daily. Advise the woman to evacuate her bowels daily and resting on a Sim’s position.
Knee-chest position. Encourage the woman to assume a knee-chest position for 10-15 minutes at the end of the day to relieve the pressure on the rectal veins.
Stool softener. If the woman already has hemorrhoids , a stool softener would be recommended.
Relieving hemorrhoids. The pain of hemorrhoids could also be relieved by applying witch hazel or cold compresses to external hemorrhoids.

Heart palpitations may occur when upon sudden movement the woman experiences bounding palpitation of the heart. This is mainly due to circulatory adjustments necessary to accommodate her increased blood supply during pregnancy.

Slow and steady. Advise the woman to move in slow, gradual movements to prevent heart palpitations.

The pressure of the uterus on the bladder causes frequent urination. Frequency occurs early in the pregnancy and late in the pregnancy.

No fluid restriction. Advise the woman not to restrict her fluids to diminish the frequency of urination, instead; caffeine intake should be diminished.
Offer assurance. Assure the woman that voiding frequently is a normal occurrence during pregnancy.
Kegel’s exercises. Kegel’s exercise also helps to reduce the incident of stress incontinence and helps regain the strength of urinary control and strengthens perineal muscles for birth.

Discomforts during the Second and Third Trimester

The last trimesters of pregnancy also have their set of discomforts that you have to differentiate from complications that might arise.

Lumbar lordosis develops as pregnancy progresses to maintain the balance.

Low heels. Advise the woman to wear shoes with low to moderate heels to reduce the amount of spinal curvature necessary to maintain an upright position.
Warm compress. Backache can be relieved by applying local heat on the area.
Body mechanics. Advise the woman to squat rather than bend over to pick up objects.
Close to center of gravity. Advise the woman to lift objects by holding them close to the body.

Dyspnea results from the pressure of the expanding uterus on the diaphragm. Dyspnea is prominent especially when the woman lies flat on the bed at night.

Proper sleeping position. Encourage the woman to sleep with her head and chest elevated.
Limit activities. Advise her to limit her activities during the day to prevent exertional dyspnea .

Late in pregnancy, some women experience swelling of the ankles and feet. The edema is caused by general fluid retention and reduced blood circulation in the lower extremities.

Watch out for proteinuria or eclampsia . Assess if the woman has hypertension or proteinuria to rule out eclampsia.
Sleep on the left side. Advise the woman to lie on her left side when resting or sleeping.
Sit. Encourage her to sit half an hour in the afternoon and in the evening with legs elevated and to avoid constrictive clothing.

From the 8 th to the 12 th week of pregnancy, the uterus periodically contracts and relaxes, and this is termed as Braxton Hicks contraction.

Give assurance. Assure the woman that these are not signs of early labor , but they can inform their healthcare provider about them.

A pregnant woman would always want reassurance that her pregnancy is healthy. These discomforts may alarm her, especially if she knows little about the physiology of pregnancy, so it is the role of healthcare providers to guide her and be there for her whenever she needs them throughout the pregnancy.

Nutritional Health During Pregnancy

One of the most important aspects in pregnancy is the woman’s nutritional status. Despite the discomfort she may feel towards eating early in pregnancy, she should never take her nutrition for granted because of the life that is dependent inside of her.

An average weight gain during pregnancy is 11.2 to 15.9 kg or 25 to 35 lbs.
For a more precise estimation of adequate weight gain, compute using the body mass index, which is the ratio of weight to height.
Weight gain during pregnancy occurs due to fetal growth and accumulation of maternal stores.
On the first trimester, approximately 0.4 kg or 1 lb per month weight gain is recommended.
On the last two trimesters, a weight gain of 0.4 kg or 1 lb per week is recommended.
Excessive weight gain occurs with 3 kg or 6.6 lbs of weight gain per month during the last two trimesters.
A weight gain of less than 1kg or 2.2 lbs in the second and third trimesters is less than usual.

Nutrition for the Pregnant Woman

The DRI or Dietary Reference Intake of calories of women of childbearing age is 2200.
For pregnant women, an additional of 300 calories for a total of 2500 calories is recommended.
This addition in calories provides more energy to the fetus and an elevated metabolic rate to the woman.
Advise woman to obtain calories from complex carbohydrates like cereals and grains because these are digested more slowly to regulate glucose and insulin.
Encourage women to prepare healthy snacks such as carrot sticks, cheese, and crackers at the start of the day.
Assess the weight that the woman is gaining so you can determine if the woman’s caloric intake is adequate.
Advice the woman not to restrict caloric intake as the fetus is rapidly growing in the final weeks.
The DRI for protein in women is 46g/d.
If protein needs are met, overall nutritional needs are met as well except for vitamins C, A, and D.
Vitamin B12 is found in animal protein; therefore inadequate protein means vitamin B12 deficiency.
Complete protein or protein that contains the nine essential amino acids can be found in meat, poultry, fish, eggs, yogurt, and milk.
Incomplete protein or the protein that does not contain all essential amino acids comes from non animal sources.
When the woman has a history of hypercholesterolemia, advise her to consume lean meat, olive oil, and to remove the skin from poultry.
Milk is also a rich source of protein, and for women who are lactose intolerant, she can add lactase supplement, take calcium supplements, or buy lactose-free milk.
Yogurt or cheese can also be a substitute for milk.
Linoleic acid is a fatty acid that cannot be manufactured by the body and must therefore be obtained from other sources.
Vegetable oils such as olive, corn, and safflower contains linoleic acid that must be consumed by the pregnant woman.
Advise the woman to avoid animal fats such as butter.
Encourage intake of omega-3 oils found in fish, omega-3 fortified eggs, and spreads.
Vitamin D which is essential for calcium absorption, when lacking in a pregnant woman would result to diminished maternal and fetal bone density.
Lack of vitamin A results in tender gums and poor night vision .
Advise the woman to consume plenty of fruits and vegetables and her daily prenatal vitamins to meet the daily vitamin intake requirements.
Advise the woman not to use mineral oils as laxative because it prevents the absorption of fat-soluble vitamins.
Folic acid is important for the production of red blood cells and can be found mostly in fresh fruits and vegetables.
Calcium and phosphorus is needed for bone and teeth formation and should be consumed by the pregnant woman.
The woman needs to ingest iodine for the proper functioning of the thyroid gland, and it is most commonly found in seafood.
The DRI for iron for pregnant women is 27 mg, so the woman must ingest foods rich in iron and iron supplements to build more hemoglobin for the fetus.
Sodium maintains fluid in the body, so it is advisable for the pregnant woman to continue adding salt into her food if not restricted.
Advise the woman to drink extra amounts of water to promote kidney function.
Encourage intake of 2 to 3 glasses of fluid daily over three servings of milk.
To prevent constipation, encourage the woman to eat plenty of fruits and green, leafy vegetables to provide fiber.
Fiber can also lower cholesterol levels and removes carcinogenic contaminants from the intestine.
The hair is shiny and strong with good body.
The woman has good eyesight especially at night; the conjunctivae are moist and pink.
There are no cavities in the teeth, no swollen or inflamed gingiva, no cracks or fissures at the corners of the mouth, the mucous membranes are moist and pink, the tongue is smooth and non tender.
The neck has a normal contour of the thyroid gland.
The skin is smooth with normal color and turgor, no ecchymosis and petechiae present.
The extremities have a normal muscle mass and circumference; normal strength and mobility , and edema are minimal.
The fingernails and toenails are smooth, pink, and normal in contour.
The weight should be within normal limits of ideal weight before the pregnancy.
The blood pressure is within normal limits for length of pregnancy.

The woman must stay healthy through the entirety of her pregnancy, and most of the nutrients she needs come from food sources. Proper health and nutrition education should be discussed by the healthcare provider to ensure that the pregnant woman is getting the right amount of nutrients that she and the fetus needs.

First Prenatal Visit

The pregnant woman’s first prenatal visit should be the building block of a healthy, happy pregnancy. Everything is established during the first visit, such as the assessment , whether the pregnancy is confirmed, and a little bit of planning for the future. It’s time to focus on the woman herself and the details that could make or break her pregnancy glow.

Initial Interview

The first prenatal interview could take a long time, so the person who is scheduling appointments for the visits should make the woman aware to avoid cancelling of appointments or rushing of the interview because the woman has an errand to attend to.
It is important that the healthcare provider should establish rapport even on the first visit because information such as what the woman feels about her pregnancy and if she has any fears can only be taken once the woman trusts her healthcare provider.
Personal interviews can also make the woman feel important and that she is not just one of the patients that would immediately be forgotten after the visit.
The interview must take place in a private, quiet environment because it would be difficult for the woman to answer all the questions when you are in a sitting room full of waiting patients or on the hallway.
The woman must also understand your role in the assessment , because if she views you only as the interviewer you would only get superficial information from her.
One of the purposes of the initial interview is to assess the health history of the pregnant woman.
Establishing a baseline health data is crucial especially when there is a new symptom that arises from the woman and it could only be identified as new based on the data gathered from her health history.
The demographic data are the superficial data that can be obtained from the woman.
These include the name, age, address, telephone number, and health insurances.
The chief concern of the woman when she visits the clinic is she thinks she might be pregnant.
Assess the first day of the last menstrual period of the woman.
Assess any early signs of pregnancy such as nausea and vomiting, fatigue, and breast tenderness.
Inquire if she has tried any home pregnancy test kit or had a pregnancy test from a clinic to establish her pregnancy.
It is important to assess any past illness because it might become active during or after the pregnancy.
Assess if there are any infections from the past, especially sexually transmitted diseases so you could educate the woman and suggest any vaccines available.
There are vaccines that are not friendly for a pregnant woman; however, vaccines such as influenza and poliomyelitis can be administered.
Assess any allergies present even before pregnancy to avoid triggers that could also affect the fetus.
Assess the presence of family illnesses such as hypertension , diabetes , or asthma on both the father and mother.
There are illnesses that could become a potential problem during pregnancy or one that could be transferred to the fetus.
Assess the woman’s current nutrition profile, or ask her to have a 24-hour recall to obtain nutrition information.
Assess the frequency, type, and amount of exercise she does to determine if her pattern of activities is still recommended during pregnancy.
Assess if the woman smokes or drinks, its frequency, and amount because these vices could cause fetal alcohol syndrome or preterm birth.
Assess history of medication intake and what medication the woman is taking during pregnancy to determine its possible effects on the fetus.
Obtain the age of the woman’s menarche, her usual cycle, the duration, and the amount of menstrual flow.
Assess any past reproductive tract surgery as it can affect the present pregnancy, such as tubal surgery from ectopic pregnancy .
Assess the reproductive planning method that the woman used or will be using after pregnancy, and also her sexual history to educate her about safe sex practices.
Assess the woman’s pregnancy history using GTPALM .
G is the gravid classification or the number of times the woman became pregnant.
T is the number of full term infants born.
P is the number of preterm infants born.
A is the number of miscarriages or therapeutic abortions.
L is the number of living children.
M refers to multiple pregnancies.
Assess the woman’s respiratory system , if she is currently experiencing cough , asthma , pain upon breathing, or any serious respiratory illnesses such as tuberculosis .
Assess the cardiovascular system and any history of heart murmurs, heart diseases, hypertension, and if she knows her blood pressure level and any experience of blood transfusion.
Assess her gastrointestinal system ; ask about her pre-pregnancy weight, any discomforts such as vomiting, diarrhea or constipation, hemorrhoids, and changes in bowel habits.
Assess her genitourinary system and ask about any urinary tract infections, STIs, PIDs, any difficulties in conceiving, and hematuria .
Assess any breast lumps, secretions, pain upon palpation of the breast, or tenderness.
Assess the woman’s last dental exam, the use of any dentures, the condition of the teeth, and if she is experiencing any difficulty in swallowing.

Laboratory Assessment

Papanicolaou smear (pap smear).

Pap smear is performed to detect and diagnose the presence of precancerous and cancerous conditions of the cervix, vulva, or vagina.
The test also reveals infectious diseases and inflammation.
The classification of Pap smear can be seen in the Bethesda classification of Pap smears.
Women who have multiple sexual partners, smoke cigarettes, have a history of HPV, and sexually active before 21 years old should have Pap smear done more frequently.
Complete blood count should be taken to assess the hemoglobin, hematocrit, and red cell index and determine the presence of anemia .
White blood cell count and platelet count must also be obtained to assess for infection clotting ability.
Blood typing with Rh factor is also important because blood needs to be available if ever the woman experiences bleeding during pregnancy.
Maternal serum alpha fetoprotein detects birth defects such as neural tube defects if elevated and chromosomal anomalies if decreased.
Antibody titers for rubella and hepatitis B or HBsAG determine whether the woman is protected against rubella and if the newborn would have a chance of developing hepatitis B .
A woman with a history of diabetes , large for gestational age babies, obese, or has glycosuria should undergo glucose tolerance test.
A 50-g oral toward the end of the first trimester should be performed to rule out gestational diabetes .
The plasma glucose level should not exceed 140mg/dl at 1 hour.
Urinalysis is performed to assess proteinuria, glycosuria, and pyuria.
These can be done through test strips or microscopic examination of the urine.
To confirm pregnancy, an ultrasound must be scheduled especially if the woman is unsure of the date of her last menstrual period.
Ultrasonography would also determine the growth of the fetus, but only the gestational sac would be seen at this stage.

Childbirth Education

Most expectant parents, especially the first timers are eager yet anxious to know the rules to becoming a parent even before the birth of their child. There are several courses or classes for parents regarding childbirth that would fill up the gap of knowledge that the couple is yearning for.

The birth of childbirth education started in the early 1900s to encourage women to involve themselves in prenatal care.
It progressed because of the additional birth choices that emerged later on.
The goal of childbirth education is to prepare expectant parents physically, mentally, and emotionally for childbirth.
Childbirth educators have a professional degree and a certificate from a childbirth education course.
Some of the topics that childbirth educators teach are the physical and emotional aspects of pregnancy, early parenthood and coping skills, and labor support techniques.
Childbirth classes are mostly taught in group; and today there are instructors who also employ the use of slides, videotapes, and demonstrations.
Childbirth education is more effective if both the parents are interactive, as they would be able to share their fears and hopes about the pregnancy and learn together as a couple.
A lot of studies have been conducted regarding the efficacy of childbirth classes when it comes to pain reduction, shortening the length of labor, decreasing the amount of medication used, and the increase of enjoyment in the overall experience of childbirth.
It is now generally accepted that childbirth courses could increase the satisfaction and control of feelings and reduce the amount of pain felt during childbirth.

The Childbirth Plan

The childbirth plan consists of the choice of setting, birth attendant, birthing positions, medication options, and plans for immediate postpartum , etc.
Classes encourage the couple to write a birth plan and deal with these issues before the day of birth to avoid stressing out at the last minute.
Make sure that the couple also understands that the birth plan should be flexible in case some complications may arise.
Preconception classes are classes for couples who are planning to get pregnant within a short span of time.
These couples most likely want to learn more about what they can expect in a pregnancy and what could be their possible birth setting and procedure choices.
The class includes recommendation of preconception nutrition changes and physical and psychological changes that pregnancy brings.
Overall, preconception classes emphasize the importance of pre-pregnancy preparations to ensure a healthy fetus and mother.
Expectant parenting classes are for couples who are already pregnant and expecting.
The focus of the topics is on the family health, nutrition during pregnancy, health changes during pregnancy, and newborn care .
Pregnant women come to these classes accompanied by their support persons, and the class usually lasts for 4 to 8 hours over a 4 to 8-week period.
The classes are individualized for each group according to their special needs, such as for adolescent pregnancy, pregnant women with disabilities, or expectant adoptive parents.
Sibling classes are designed for older brothers and sisters to give them awareness of what would happen during birth and what they can expect a newborn would act like.
Simple things that a child can do during the period of pregnancy, such as eating nutritious food together with their mother and how babies grow are taught in these classes.
The information given during sibling classes should be appropriate to their age to make sure that the classes are effective.
Women who take breastfeeding classes appreciate over time the importance of breastfeeding and the advantages it gives both the mother and the baby.
Topics include the physiology of breastfeeding, its psychological aspects, and the advantages of exclusive breastfeeding.
The classes would also emphasize on ways on how a busy mother could still breastfeed her child despite a busy work schedule so the breastfeeding could continue for at least the first full year of the baby.
The focus of preparation for childbirth classes is mainly in the birth process.
The class would help the woman and her support person prepare for the childbirth experience.
Pain management and reduction is also a part of these classes, both with nonpharmacologic and pharmacologic measures.

Pain Management During Labor

Also known as the Partner-Coached Method, it centers on the idea that the woman’s partner should play an important role during pregnancy, labor, and childbirth until early newborn care.
Originated by Robert Bradley, it sheds light on the fact that pregnancy and birth are joyful natural processes.
The woman is taught to use an internal focus point as a disassociation technique, and she is encouraged to walk during labor.
This is a method proposed by Grantly Dick-Read wherein the premise is that fear leads to tension, which leads to pain.
The idea is for the woman to prevent the fear and break the chain between tension and pain, so she can reduce the pain of labor contractions.
Lack of fear is achieved through education on childbirth and relaxation, and pain management techniques.

The Lamaze Method is one of the most widely taught methods in the United States.
The theory is based on stimulus-response conditioning, wherein women can learn to use controlled breathing to reduce the pain of labor.
Formal classes are organized by Lamaze International or the International Childbirth Education Association.
Topics from Lamaze include prenatal nutrition and exercises, common discomforts of pregnancy, and information to prepare couples for unexpected circumstances such as cesarean birth or the need for anesthesia .
The gating control theory of pain is emphasized in Lamaze where the use of controlled breathing and imagery can block incoming pain sensations.
Lamaze classes are kept small so that there would be enough time for individualized instruction and attention to each couple.
The support person that the woman brings would act as her coach in labor.

The Birth Setting

One of the most important choices that a couple should also consider is the birthing center where their baby would be delivered. Choosing the place where the woman would give birth depends on the health of both the fetus and the mother, and should be in accordance with the preferences of the kind of assistance the couple would want during delivery.

Hospitals have not always been the place for birth. In earlier times, childbirth always takes place at home without any analgesia and the women give birth the natural way. However, today a lot of birthing choices were developed, and birthing centers have become hospitals instead of at home.

Women are still given the freedom to choose where they would want to give birth provided that the woman does not have a complicated pregnancy, and the health of the fetus is stable.
Women who have complicated pregnancies have less freedom in choosing that the usual because they are advised to give birth only at hospitals for provision of emergency care if needed.
Birthing centers are now fully equipped with resources that could compete with hospital facilities, which is why most couples consider giving birth here than going to the hospital.

Most women who give birth are always attended to by their physicians or obstetricians. But as there are more and more courses offered for family practitioners to become certified birth attendants, even with only a midwife or nurse -midwife to attend to a birth is now considered as appropriate and preferred by couples.

Alternative birthing centers employ more nurse-midwives to attend to births.
Another consideration that a woman should make is who would become her support person during labor up until her delivery.
In the past, experienced women in the community take up the role of the support person.
Later on, support persons became the father of the baby.
Today, any family member may take up the role of a support person.
Doulas are also preferred by more women today, as an addition to their support person.
Doulas are women who are specially prepared to assist with childbirth, and they are helpful especially when the support person would find it hard to provide enough support during labor.
When a woman’s support person becomes too emotional to assist the woman in labor, the doula could take in charge to allow the father or any support person to enjoy the experience and involve them emotionally in the situation.
The support of the doula can also reduce the rates of cesarean births, epidural anesthesia, and oxytocin augmentation, according to some research.

Hospital Birth VS Alternative Birthing Centers

Hospital birth has always been preferred by women when they want to ensure their safety during delivery and to be certain that the baby would be handled by professionals. However, the emergence of alternative birthing centers gave women the chance to choose which setting they would want to give birth in, as both could have advantages and disadvantages to consider.

Hospitals have standards when it comes to their maternity services as influenced by the First Consensus Initiative of the Coalition for Improving Maternity Services.
The organization provides a set of practices that would make a hospital mother and baby friendly.
The mother should be able to consider her experience as healthy and joyous regardless of her age or circumstances.
The mother should have access to a full range of options regarding her pregnancy, birth, and care of the newborn.
The mother should receive utmost support when it comes to her birthing choices based on her beliefs or culture.
The mother should be allowed to give birth in any environment where she would feel safe and secure.
The mother should receive information and updates about anything that could affect her pregnancy and her baby, with the rights to informed consent and refusal.
At hospitals, women are encouraged to control the discomfort and pain of labor through nonpharmacological measures despite the availability of epidural anesthesia.
Information is readily given to women regarding the birthing process and to help her decide on procedures that would be performed.
Breastfeeding is highly encouraged at hospitals to promote bonding between the mother and the baby and to aid in uterine contractions.
Labor, birth, and postpartum care can be done in one single room at hospitals which could provide more ease and comfort for the woman.
Skilled professionals attend to the woman during birth, and emergency care is readily available if the situation warrants it.
However, the family and the woman might be separated for one night during delivery, and the mother may sometimes feel that she is not in full control of her experience.
Alternative birthing centers are wellness-oriented childbirth facilities that encourage birth outside of the hospital setting while still being able to provide medical resources appropriate for any emergency that might arise.
Nurse-midwives attend to the birth at ABCs.
Before a woman is permitted to give birth at an alternative birthing center, she is screened for complications first to avoid increasing the mortality rate of mothers and infants in this setting.
Women are also encouraged to deal with labor pain through nonmedical measures.
Family members are allowed to accompany the woman throughout the experience.
Skilled professionals attend to the woman during birth, and emergency care is also readily available.
High-risk care may not be easily and immediately arranged at alternative birthing centers.
The stay of the woman at the facility may only be brief, so fatigue is most likely encountered after birth.
The woman is also expected to monitor her postpartal status independently because of her brief stay in the healthcare setting.
Women remain at the ABC 4 to 24 hours after birth because the woman can recover quickly because of the minimum analgesia used.

Content of First Prenatal Visits

The purpose of this study was to examine the content of the first prenatal visit within an academic medical center clinic and to compare the topics discussed to 2014 American College of Obstetrics and Gynecologists guidelines for the initial prenatal visit.

Clinical interactions were audio recorded and transcribed (n = 30). A content analysis was used to identify topics discussed during the initial prenatal visit. Topics discussed were then compared to the 2014 ACOG guidelines for adherence. Coded data was queried though the qualitative software and reviewed for accuracy and content.

First prenatal visits included a physician, nurse practitioner, nurse midwife, medical assistant, medical students, or a combination of these providers. In general, topics that were covered in most visits and closely adhered to ACOG guidelines included vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Topics discussed less often included many components of the physical examination, education about pregnancy, and screening for an identification of psychosocial risk. Least number of topics covered included prenatal screening.

Conclusions for Practice

While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study. Identifying new ways to disseminate information during the time constrained initial prenatal visit are needed to ensure improved patient outcomes.

Introduction

A significant and long-standing problem in healthcare is the timing, volume, and variety of care and education that could be covered during busy prenatal visits. Guidelines for the content of the first prenatal visit have been developed and endorsed by a variety of professional and public health organizations for over a century. The most recent guidelines for prenatal care, including first prenatal visits, are the 2014 American College of Obstetricians and Gynecologists (ACOG). Early and complete first prenatal visits are promoted as opportunities for screening, identifying, and addressing risk factors to improve pregnancy outcomes, provide important pregnancy education information, and establish the importance of prenatal care. However, little is known about how these guidelines are actually applied in the first prenatal visit.

There has been a rapid expansion of knowledge about the importance of the mother’s health before and during pregnancy and an increase in the number of topics to discuss within a time limited clinical encounter to adequately care for pregnant women. For example, ACOG recommends that all pregnant women, regardless of age, disease history or risk status, be routinely offered prenatal genetic screening (" ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities," 2007 ). Some research indicates that discussing the importance of breastfeeding during the first prenatal visit may increase rates and duration of breastfeeding ( Chung et al., 2008 ; " Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force recommendation statement," 2008 ). However, most care and education provided to women is decided upon by the individual prenatal care provider. It is unknown what care is typically provided and what topics are discussed, especially in the first prenatal visit. Before any interventions or educational tools are developed to improve how prenatal education and screening options are communicated to women, we first need to understand what care is actually provided and what health education topics are discussed.

The goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother through the determination of gestational age, identification of maternal risks, ongoing evaluation of the health status of the mother and fetus, anticipation of problems and necessary interventions, and patient education and communication ( ACOG/AAP, 2012 ). Early prenatal care also focuses on assessing maternal risk factors to support early intervention, providing of advice, offering health education, and teaching ways to address the minor problems of pregnancy ( Al-Ateeq & Al-Rusaiess, 2015 ). However, guidelines for this content vary greatly and have been criticized for failing to focus on the pregnant woman ( Hanson, VandeVusse, Roberts, & Forristal, 2009 ).

In 1925, the U.S. Department of Labor issued the Standards of Prenatal Care: An Outline for the Use of Physicians ( U.S. Department of Labor, 1925 ). Sixty years later in 1989, the U.S. Public Health Service issued a report describing the components of prenatal care, basing their recommendations on the current scientific evidence ( PHS, 1989 ). Adherence to these guidelines, as well as the 1959 ACOG guidelines, was examined in the late 1980s. Kogan et al. examined providers’ adherence to the subsequently published US P.H.S. 1989 guidelines by interviewing almost 10,000 pregnant women. Almost half of women reported that they failed to receive the recommended early prenatal examinations, laboratory tests, and health education ( Kogan, Alexander, Kotelchuck, Nagey, & Jack, 1994 ). Baldwin, et al. (1994) examined the adherence of 249 prenatal care providers (obstetricians, family physicians, certified nurse midwives) to the ACOG Guidelines of 1959 that had been in place for almost 30 years. They found that the providers followed the well established guidelines on average 80–90% of the time (range 13% to 94%).

The broad categories in these historical documents remain much the same in the most recent guidelines issued by the American College of Obstetricians and Gynecologists (2014) and separately by the American Academy of Family Practice ( Zolotor & Carlough, 2014 ). However, there has been a significant increase in the content of each category with many more patient history questions, laboratory tests, and health education topics recommended on the first prenatal visit. The result of this increased burden in terms of adherence has not yet been examined. The purpose of the current study was to examine the content of the first prenatal visit within a university hospital clinic. Clinical interactions were audio recorded and the content analyzed to identify adherence to the 2014 ACOG guidelines (" ACOG Committee Opinion no. 598: Committee on Adolescent Health Care: The initial reproductive health visit," 2014 ).

Thirty first prenatal visits were audio recorded. The purpose of the recordings was described to the providers and pregnant women as assessing the type of topics covered in the prenatal visit, such as breastfeeding, vitamins, and prenatal screening. Data collection occurred in a Level 3, academic medical center obstetric clinic serving a diverse group of women receiving care under a variety of health care payment plans. All providers of care and patients were eligible for participation in this study. Patients being seen for their first prenatal visit were approached for study consent and enrolled in the examination room. Providers of care were obstetricians (MDs), certified nurse midwives (CNM), nurse practitioners (NPs), and medical students (MS). Staff involved were medical assistants (MAs). Some first prenatal visits included either an MD or NP, an MD and an NP, a CNM, and an MD and a MS. The recorder was turned on when the patient consented and prior to any interactions with a provider. The recordings were stopped when the patient exited the examination room. Audio-recordings were later transcribed verbatim and were used in the analysis. All visits took place between October 2014 and December 2014. The study was approved by the University of Utah Institutional Review Board and all patients signed written informed consent prior to any study procedures.

Audio recording transcripts were read in their entirety by the researchers. ACOG recommendations for content of first prenatal visit topics were used for comparative analysis (see Table 1 . ACOG Guidelines). The transcribed text for all first prenatal visits were uploaded into ATLAS.ti® for analysis. ( Atlas.ti, 2015 ). A qualitative content analysis was used to analyze the data. A distinguishing feature of a content analytic approach is the use of a consistent set of codes to designate data segments that contain similar material ( Elo & Kyngas, 2008 ). Consistent with our work ( Author et al., 2012 ; Author et al., 2011 ), the codes were generated from the data, and rather than using search algorithms, careful readings of the data were performed to generate the codes. Then the codes were systematically applied to the transcripts, with the ability to add codes that might have been missed with the initial development of the codebook. After coding was completed, they were summarized to identify the most frequently reported topics across the clinical visits. We addressed trustworthiness and rigor of the data to maintain data integrity during the analysis through methods of credibility and auditability ( McBrien, 2008 ). Upon completion of the coding, all data were queried within Atlas.ti® and reviewed by the research team. This allowed reviewing, verifying, and auditing the coding schema and associated data.

Percent of Visits – Adherence to ACOG Guidelines Overall (n=30 clinic visits)

After the initial analysis was complete, the content of the clinical visits was compared to the ACOG guidelines for the first prenatal visit (see Table 1 ). Any text addressing any component of each of the ACOG categories was counted as addressing the category. Incidence and density of topics were determined by the frequency of codes. However, because we relied only on verbal content, some aspects of the physical exam may have been missed if the provided did not mention it (i.e. I am taking your blood pressure now.) Descriptive statistics were used to further characterize the adherence to ACOG recommendations in these first prenatal visits by type of provider (see Table 1 ).

The analysis included thirty separate clinical visits of women seen for their first prenatal visit. An unknown number of providers of care were included and some providers could have been included more than once. Data collection was over one month and allowed a range of different providers and patients to be included in this study. Selection of participants and providers was random. Of the providers recorded there were 5 visits that included both an MD and NP, 8 visits with NP only, 14 visits with MD only, 2 with a MD and MS, and 1 with CNM. All participants and providers were English speaking. Demographic data for the patients and providers were not collected. The primary purpose of this study was the visit content discussed and adherence to ACOG guidelines for the initial reproductive visit.

Incidence of Topics Discussed

ACOG Guidelines provide a comprehensive list of topics for education and counseling to be provided at the first prenatal visit. The percent of visits in which adherence to ACOG Guidelines was identified is shown in Table 1 . Identification of adherence included mere mention of a topic and extensive discussion and/or provision of specific ACOG-recommended care or patient education. Yet, the time devoted to each topic was not accessed. In other words, these results do not represent the extent or the amount of time dedicated to the specific recommended content of prenatal care.

In this study, a clinic overview was provided to every woman. This included a number of topics, i.e. schedule of visits, availability of providers, and making appointments. In almost every visit, there was evidence of some history taken or a portion of a physical examination provided, as well as mention of routine blood testing.

Discussion of cervical cancer / pap smears and urine testing occurred in 80–83% of the visits. A confirmatory examination for pregnancy in this sample, largely represented by auscultation of fetal heart tones, occurred in three quarters of the visits. A discussion of routine laboratory testing and available genetic testing was found in 70–75% of the visits. Prenatal vitamins and iron were also routinely addressed in over 70% of visits, and flu vaccine was offered (57%).

Gathering of a family medical history, assessment of and education about alcohol, tobacco, and / or drugs were found in slightly over half the visits. Exercise counseling occurred in about half the visits. As specific complications were not known for each woman, any mention of complications in the transcripts, such as twins or vaginal birth after cesarean, was counted as fulfilling the ACOG recommendation, occurring in 26% of visits. Any discussion of the process of pregnancy was identified as fulfilling the ACOG recommendation of educating the women about the expected course of pregnancy, found in 20% of visits. Psychosocial needs assessment visit guidelines were followed in less than 10%.

None of the recordings indicated that a complete initial history, assessment for pre-term labor risk, or complete physical examination was completed (i.e. abdomen, breasts and inquiries about bladder and bowel functions, weight gain, and vital signs). ACOG guidelines indicate a complete needs assessment should be done. This complete assessment was not found on recordings of any visits although additional visits could have addressed these patient needs. Screening for domestic violence or depression was not found in any recording, with depression rarely addressed in the first prenatal visit. Education on most ACOG recommended first prenatal visit topics (labor & delivery, working, air travel, dental care, over the counter medication use, pets and seat belt use) was rarely or never found on recordings. Psychosocial issues were rarely addressed on the audio tapes. Prenatal classes, while often not attended until late in pregnancy, were never mentioned nor was there an investigation of any barriers to receiving care in any visit. Specific content of the routine laboratory and diagnostic testing was not discussed in the recordings or known to researchers. As no histories of the women were available to researchers, women who were at risk for gestational diabetes (GDM) or pre-term labor were not identified to know who merited education or early screening. GDM screening was not discussed with any woman.

First prenatal visits are often scheduled throughout an MD / CNM / NP’s clinical day, interspersed with other types of pregnancy and gynecologic patient visits. Providers work under time constraints with multiple patients scheduled in quick succession. This can result in abbreviated visits, omission of ideal health education, reliance on other staff to collect information and provide patient education, and addressing only the most obvious problems. Given clinical time constraints, many providers rely on provision of printed materials to patients to compensate for the lack of time available for direct face-to-face patient education. Whether printed materials are an effective or optimal approach to delivering patient education or not, is questionable ( Nolan, 2009 ). Further, some topics may be discussed in future visits to account for the limited time in only one clinical visit.

The study results suggest that several ACOG guidelines are being addressed, particularly those related to medical care and intervention – vitamins and iron, blood and urine laboratory studies, flu vaccine, and screening for cervical cancer. However, the extent of discussion or amount of time dedicated to meeting ACOG recommendations, are unknown. For example, the mention of “genetic screening” in the transcribed audio recording was coded and reported as “addressed” during the prenatal visit. However, genetic screening is a complex topic and it is unknown if it was fully discussed during the visit or was it merely mentioned that information about genetic screening as provided in the printed material distributed to the patient.

It is unknown what information was already contained in the EMR, although the EMR format is known to allow for the documentation of all the ACOG recommended information. Initial historical information, family history, genetic history, and risk of pre-term labor could have already been in the EMR or data could have been entered outside the examination room. Video recordings, rather than audio recordings, could have revealed that a physical examination occurred, as there was no specific mention of a completed physical examination in the audio recording. Finally, as discussed above. first visit prenatal education recommended by ACOG may have occurred in a different formast, for example, printed materials distributed to patients. Further, some of the patients may have undergone a “confirmatory pregnancy” appointment and topics not discussed in this recorded visit could have occurred as well as in future visits. Audio recordings revealed that packets of prenatal information were often given, however the exact content is unknown.

The prenatal visit discussions in this study were focused on information gathering with mostly closed ended questions used by providers, usually resulting in patient responses of “yes or no”. This style of questioning discourages full and meaningful responses that could have provided additional information of importance to patient care. The providers in this study addressed concerns that were expressed by the women, but rarely asked women about their concerns or fears. Discussing a woman’s concerns and fears can reveal risk factors that should be addressed or a further discussion can allay fears once identified. Many providers referenced the authoritative recommendations of health care profession groups, such as ACOG and others, without further discussion. An explanation of the risks, benefits, and/or alternatives to that recommended care was rarely offered.

A larger question that should be considered is how the content of the ACOG recommendations can be addressed while including patient driven needs and preferences in these guidelines. Many of the components of the ACOG Guidelines are based on tradition with a limited number of topics supported by careful research ( Zolotor & Carlough, 2014 ; Kirkham, Harris, & Grzybowski, 2005 ). Further research is needed to explore the value of all of the components, with the goal of including only those that have proven value. Women’s needs and preferences have not been routinely included in published guidelines ( Hanson et al., 2009 ), implying that these are of lesser importance or additional avenues outside the clinic visit need to be explored to address patient.

Lastly, forming relationships with patients requires time, the use of open-ended questions, and repeated visits. It is unreasonable to assume that such a close relationship will occur at the first prenatal visit. This study demonstrated the issues of provider time constraints based on their recorded comments are related to lack of adherence to ACOG’s education recommendations,, and lack of screening for unstated problems.

Limitations

This study took place in one outpatient clinic in a Level 3, academic medical center obstetrics clinic. Other practice settings, such as a private office, birth center or home birth setting, may structure first prenatal visits very differently. The majority providers of care were MDs and no comparisons can be made of their care to the care of the few CNMs or NPs in this study. Further, the content of the visit was descriptively compared between different providers. It would be interesting to assess how different professionals prioritize different topics during time limited clinical encounters as well as how patients’ driven questions influence the topics covered. Researchers lacked access to knowledge about existing information in the EMR or when the EMR was used. Audio recordings missed the visual information and nuances of a video recording, which would have provided additional information about first prenatal visit content. Lastly, content analysis did not address the extent to which ACOG guidelines were followed, nor the amount of time dedicated to provision of care or patient education. Future studies should include these aspects of ACOG guideline adherence to better understand the effectiveness of prenatal care and include additional prenatal visits.

This study demonstrated that standard ACOG guidelines for first prenatal visit content were inconsistently followed at one site by one group of providers based on audio recordings. Providers more closely adhered to ACOG guidelines that addressed vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Content addressing many components of the examination, education about pregnancy, and screening for an identification of psychosocial risk was identified less often. Providers routinely used an interview style that did not elicit extensive information. While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study.

Acknowledgments

We would like to thank the University of Utah College of Nursing Research Committee for helping fund this study.

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IMAGES

Prenatal Testing
Prenatal Testing
Antepartum Care
First Prenatal Visit: Nursing Assessment and Management
Guide to Prenatal Genetic Testing and Screening
Your First Prenatal Visit

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The first prenatal care visit
OUR FIRST PRENATAL VISIT TO THE DOCTOR AND WE ARE HAVING TWINS??

COMMENTS

Prenatal care: 1st trimester visits
Lab tests. At your first prenatal visit, blood tests might be done to: Check your blood type. This includes your Rh status. Rh factor is an inherited trait that refers to a protein found on the surface of red blood cells. Your pregnancy might need special care if you're Rh negative and your baby's father is Rh positive. Measure your hemoglobin.
Prenatal care: Initial assessment
The three main components of prenatal care are: risk assessment, health promotion and education, and therapeutic intervention [ 1 ]. High-quality prenatal care can prevent or lead to timely recognition and treatment of maternal and fetal complications. Complications of pregnancy and childbirth are the leading cause of morbidity and mortality in ...
Routine Tests During Pregnancy
Certain lab tests are part of routine care during pregnancy. Some of these tests are done with a blood sample. Others use a urine sample or a sample of fluid taken from your vagina, cervix, or rectum. These tests can help find conditions that may increase the risk of complications for you and your fetus. Many problems found by these tests can ...
Routine blood tests during the first trimester of pregnancy
1. Blood type, Rh factor, and antibody screening. At your first prenatal visit, your practitioner will check your blood type to see whether it's type O, A, B, or AB, and whether it's Rh-negative.. If you're Rh-negative (15 percent of people are), you'll get a shot of Rh immune globulin (Rhogam) at least once during your pregnancy, and another after you give birth if your baby turns out to be ...
PDF Guidelines for Routine Prenatal Care
Prenatal care visits should occur with the following frequency: Prior to 20 weeks, ideally every 4 weeks but no less than every 6 weeks for lower-risk women. 20 to 28 weeks, every 4 weeks. 28 to 36 weeks, every 2-3 weeks, 3 weeks for lower-risk women. 36 weeks to delivery, at least every week. Urine dipstick for protein, glucose, and ketones ...
Prenatal care in your first trimester
Your First Prenatal Visit. You should schedule your first prenatal visit soon after you learn that you are pregnant. Your doctor or midwife will: Draw your blood. Perform a full pelvic exam. Do a Pap smear and cultures to look for infections or problems. Your doctor or midwife will listen for your baby's heartbeat, but may not be able to hear it.
What To Expect at Your First Prenatal Visit
During your first trimester, your provider will check your blood to determine your blood type and look for signs of: Blood issues, such as anemia (low iron). Immunity to rubella (German measles ...
Prenatal Panel: MedlinePlus Medical Test
A prenatal panel usually includes the following tests: Complete blood count (CBC). This test measures the different parts and features of your blood, including red blood cells, white blood cells, and platelets. A CBC can help diagnose a variety of health problems, such as anemia, clotting disorders, and infections. Blood type and Rh factor.
First trimester tests during pregnancy
Pelvic exam and Pap smear. Prenatal testing during the first trimester begins with a pelvic exam and Pap smear to check the health of your cervical cells. This testing screens for cervical cancer ...
Prenatal Testing Checklist: Regular Tests for Each Trimester
Ultrasound screening (weeks 18-20) At this stage, the ultrasound is used to assess the placenta, fetal anatomy, activity, growth rate, and blood circulation; as well as determining amniotic fluid volume and measuring the cervical length. Several blood tests at 15-20 weeks (ideally weeks 16-18) to screen for markers suggestive of genetic ...
Prenatal care and tests
After the first visit, most prenatal visits will include: Checking your blood pressure and weight; ... If your doctor suspects a problem, the sample might be sent to a lab for more in-depth testing. You will collect a small sample of clean, midstream urine in a sterile plastic cup. Testing strips that look for certain substances in your urine ...
First-Trimester Exams and Tests
At each prenatal visit during your first trimester, you'll be weighed and have your blood pressure checked. Your urine may also be checked for bacteria, protein, or sugar. As early as weeks 10 to 12, you may be able to hear your baby's heartbeat using a Doppler ultrasound. By the 20th week, the heart tone is strong enough to hear with a special ...
Your First Prenatal Appointment
The most common tests at your first prenatal visit will likely include: [3] Urine test. Your urine may be checked for protein, glucose (sugar), white blood cells, blood and bacteria. Bloodwork. A sample of your blood will be used to determine blood type and Rh status and check for anemia. Trusted Source Mayo Clinic Rh factor blood test See All ...
FAQ About Your First Prenatal Visit
The first prenatal check-up is usually scheduled around week eight of pregnancy, or, at least, ideally before week 10. It's a good idea to schedule your first prenatal appointment once you get a positive pregnancy test. The first prenatal visit is significant because getting prenatal care on time is a vital step in a healthy pregnancy.
1st Trimester: 1st Prenatal Visit
1st Trimester: 1st Prenatal Visit. It's the first doctor visit of your pregnancy. Congratulations! During this visit, your doctor will check your overall health and determine your due date. They ...
Update on Prenatal Care
Women should be screened for rubella immunity during the first prenatal visit. C: 6, 9, 11: Pregnant women should be screened for asymptomatic bacteriuria between 11 and 16 weeks' gestation. A: 6 ...
Your first prenatal appointment: What to expect
At that visit, we will discuss your overall health, answer your first round of questions and help you prepare for the next nine months. Most women make an appointment after they get a positive result from a home pregnancy test. Often, this is one or two weeks after a missed period. Call us at 505-272-2245, and we will schedule your first ...
Before Your First Prenatal Visit
Your first prenatal visit will likely be your longest visit. Your care team will ask about your medical history (menstrual cycle, birth control, past pregnancies, previous surgeries, family history and medications). They will also perform a physical exam and order routine lab tests. Your care team will let you know what your expected due date ...
Prenatal Blood Tests on Your First Visit
First visit prenatal tests. Most people associate the word "pregnancy test" with an initial test to check if you are pregnant or not, either a urine or a blood test. However, there are many more tests done during pregnancy, once you know that you are pregnant. As part of routine prenatal care, certain blood and other tests are usually done ...
Your First Prenatal Visit
If you did not meet with your health care provider before you were pregnant, your first prenatal visit will generally be around 8 weeks after your LMP (last menstrual period ). If this applies to you, you should schedule a prenatal visit as soon as you know you are pregnant! Even if you are not a first-time mother, prenatal visits are still ...
Pregnancy Changes and Prenatal Visits Nursing Care
First Prenatal Visit. The pregnant woman's first prenatal visit should be the building block of a healthy, happy pregnancy. Everything is established during the first visit, such as the assessment, whether the pregnancy is confirmed, and a little bit of planning for the future. It's time to focus on the woman herself and the details that ...
Content of First Prenatal Visits
First prenatal visits included a physician, nurse practitioner, nurse midwife, medical assistant, medical students, or a combination of these providers. In general, topics that were covered in most visits and closely adhered to ACOG guidelines included vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening.