We’re continuing our series on routine prenatal care around here and shifting the series to Mondays instead of Wednesdays! With the bulk of the laboratory testing, physical exam and an established due date, routine obstetric care moves into a prevention, assessment and education cycle.
The point of this series is two-fold:
- Provide education from the evidence on the components each prenatal visit.
- Offer a tool to guide the mama/family and provider through all the recommended components of the visit while offering a vehicle for the woman to take home that reviews everything covered at the visit and a list of additional resources for education and information.
If you missed the IOB visit (initial OB visit), you can check out all the details here. The template is always available on the RESOURCES page to download or share for free.
What are the components of the 14-16 week visit?
- Overall assessment of woman and her baby
- A review of symptoms or patient concerns with attention/intervention to each concern as appropriate
- A screening (if indicated, often for depression/anxiety or intimate partner violence)
- A brief physical exam
- A review of an ultrasound report, laboratory/genetic screening results, or other results
- Pertinent education
- A review of warning signs and recommended follow up (American Academy of Pediatrics [AAP], & American College of Obstetricians and Gynecologists [ACOG], 2017); King et al., 2015)
Let’s break it down!
Review of symptoms or patient concerns
These are any symptoms that have occurred since the last visit with the provider that the patient desires to discuss with the provider. An example is: “I think I have a yeast infection because there are white chunks coming out of my vagina and it itches.” Or, “I had a yeast infection two weeks ago but I used Monistat over the counter and my symptoms disappeared. Was this okay to do?”
Common questions for this visit include…
- I haven’t felt my baby move yet. Is that normal?
- Is it okay to have sex?
- How much caffeine can I have each day?
- Should I be working full time?
- Can I travel while pregnant? Can I get on an airplane?
- Can I go running or to spin class?
- Can I take a bath?
- Can I get in a hot tub?
- Can I eat sushi?
- Should my partner change the litter box?
- Is it okay that I am taking a nap every day?
- I’m not sleeping well – what can I do to sleep better?
- When am I going to find out the gender?
- Can I take gummy prenatal vitamins?
- Can I get my hair done? My nails too?
- What can I do about round ligament pain?
- Why don’t I have to pee in a cup every visit?
Most of these questions tell your provider that you’re feeling a little better than the last visit to the clinic and that you have had a return of energy and less fatigue, nausea and vomiting. If you’re looking for the answers to those questions, follow the instagram this week for the answers (@amidwifenation).
Because it’s a routine visit, the review of system questions are targeted to pregnancy unless the woman’s history or questions indicate investigation and follow up. These questions are generally the same at every visit for the rest of pregnancy.
The questions are:
- Are you feeling your baby move?
- Are you having any vaginal bleeding, leaking of fluid, abdominal pain or contractions?
- Have you had any visits to the emergency room since your last visit? (AAP & ACOG, 2017)
After the routine questions, I have some favorite questions that I like to ask during this visit. A lot of these questions are centered around a return to energy (although fatigue and extra naps are still very normal), return to normal appetite, and changes in sleep habits or patterns. I also like to review weight gain, nutrition and exercise.
These are some of the questions I ask at the 16 week visit:
- Has your energy returned?
- How are you sleeping?
- What kind of exercise are you doing?
- Has your appetite returned?
- Do you have any back or pelvic pain?
- What do you know about breastfeeding?
- What are your plans for education about pregnancy and childbirth?
Screenings are usually completed in a number of fashions – sometimes by the tech asking the woman questions or by having the woman fill out a piece of paper.
Screening for psychosocial factors is an important part of prenatal care. Some risk factors (i.e. homelessness, loss of job, smoking, drinking, moving…) are present before prenatal care and some factors happen during the pregnancy or postpartum. To increase the number of opportunities to provide timely intervention, support or referral, ACOG & AAP (2017) recommend screening on a regular basis during prenatal care and documentation of each screening in the prenatal record.
If the woman has a history of depression or anxiety, reports new symptoms of either depression or anxiety, or is on medication for mood management, a screening is appropriate to assess her mood and risk. ACOG (2015) only recommends screening once during the perinatal period and once a the postpartum period.
Screening tools vary across practices and regions of the world. In the United States, the most common tools used for screening in pregnancy at the EPDS or the PHQ (PHQ-2 or PHQ-9).
It is always appropriate to ask that the provider review your screening results with you. A screening tool is very valuable. And sometimes a woman may feel uncomfortable talking about her mood even though she knows something isn’t feeling quite right. A positive screening is a flag for your provider to ask more questions and also review options for support, counseling or resources.
The Exam, Lab Testing, and Ultrasounds
Once the pregnancy is established, the exam is limited to checking for normal progression of the pregnancy.
- Vital signs (weight, blood pressure, pulse)
- Weight is an indicator of many things. It can tell your provider how severe your nausea or vomiting is, or, how often you eat fast food. Weight gain recommendations are based on BMI and most weight gain up to 16 weeks is an increase in blood volume and breast growth.
- Blood pressure is another indicator of health in pregnancy. Typically, your blood pressure is the highest at your very first pregnancy visit and then the lowest in the second trimester.
- Temperature is checked depending on the practice you work in.
- Fundal height (the location of the top of your uterus as palpated by the provider in relation to either you pubic symphysis or your umbilicus)
- The height of your uterus tells the provider is the pregnancy is growing normally. A uterus that is higher in the abdomen than expected could be a twin gestation, a full bladder, and just the habitus of a woman. Typically, the fundal height is palpated up to 20 weeks. At 20 weeks, the height of the fundus is measured with a measuring tape and should measure within 1-2cm of the actual gestation of the woman.
- Auscultation (listening) to the baby’s heart rate
- The most exciting part of the visit! Most providers use a handheld doppler to measure to the baby’s heart rate but the heart rate can also be assessed by ultrasound machines. Normal fetal heart rates are between 110-160 beats per minute and heart rates are higher at the beginning of pregnancy.
Most 16 week visits do not include an ultrasound. Ultrasounds “should be performed only when indicated and should be appropriately documented” (AAP & ACOG, 2017, p.176). Some obstetric providers perform an ultrasound at every prenatal visit. This is not the standard of care and is done for billing purposes (i.e. the provider can bill and code for more money if they perform an ultrasound at your visit). Occasionally, it is difficult to find fetal heart tones with a doppler; in these cases, a limited ultrasound is done to confirm the fetal heart rate.
Lab testing at 16 weeks consists of catching up any outstanding labs from the initial OB visit and any pertinent genetic (carrier or aneuploidy) screening. Screenings vary greatly across the United States and the area of the country you live in. Insurance providers also vary. For these reasons, the series won’t go into detail about genetic screening – it really deserves it’s own post or tool!
The is so much education to offer at 16 weeks. Most women have had a great return in energy and aren’t so tired. There is also a peak in eagerness to learn about the pregnancy and the interventions for the common discomforts of pregnancy. These are the common areas of education, but the sky really is the limit and varies greatly from provider to provider.
The first trimester is wrought with constipation because the hormone progesterone slows down the activity of the bowels. Well really, progesterone slows down everything – you are growing a baby! There are a lot of things you can do to manage constipation but learning about what causes constipation and how to incorporate some lifestyle changes can really make the difference in your bathroom time and help prevent hemorrhoids. One of the best handouts I’ve seen on constipation is from the American Urogynecologic Society.
During pregnancy, and in the absence of a complication or guidance to exercise, ACOG & AAP (2017) recommend 30 minutes of moderate exercise most or all days during pregnancy. Exercise is so important that it’s one of the main factors implemented in women who are diagnosed with gestational diabetes in pregnancy. One of the best time to go for a brisk walk is right after you eat a meal. If you are walking after mealtime, your body doesn’t need insulin to get glucose into your cells! The only guidance ACOG & AAP offer regarding exercise is to avoid exercise with a high risk of falling or abdominal trauma (2017). Each exercise program should be weighed for risk factors.
The following warning signs are reasons to stop exercise:
- Chest pain
- Vaginal bleeding
- Decreased fetal movement
- Amniotic fluid leaking
- Muscle weakness
- Calf pain or swelling
- Regular uterine contractions (AAP & ACOG, 2017)
I really like for woman to set goals for exercise during pregnancy. It’s a really long period of time to set up some good habits for after the baby arrives. I had one patient that made a goal to do 100 spin classes before her due date!
Most women feel the first little kicks of their baby (or babies) around 16 to 18 weeks. Fetal movement is a sign of fetal wellbeing. Movement varies from trimester to trimester. The Royal College of Obstetricians & Gynaecologists has one of the best handouts I’ve seen! In short, it’s good to review when a mama is going to first feel her baby move and what she should expect in the days and weeks to follow!
Round ligament pain
Most women have had some round ligament pain by their 16 week visit, but many don’t that is what their pain was or what caused it. The pain is usually felt when the mama moves from sitting to standing quickly, rolls from one side to the other in bed, or has a puppy or other small child pounce on their lower belly. The pain is from the insertion points of the round ligament. The ligaments work to hold the uterus steady but there are always some movements of the uterus from side to side or front to back. Movement that trigger the sharp pain felt as ’round ligament pain’ are when the ligament or ligaments are strained or stretched too quickly.
Weight gain and Nutrition
Weight is a vital sign. A provider should address a woman’s weight gain at every visit and give guidance and reassurance about her weight in relation to the guidelines below. This is an area where providers have a lot of room to improve. Most clinics have a nurse complete the prenatal education for a patient and then the woman doesn’t hear about her weight for the rest of her pregnancy.
Women can track their weight at home in between prenatal visits with a simple scale purchased from any store.
Closely tied to weight gain is nutrition. The 2020-2025 dietary guidelines for pregnant and lactating women offer a nice chart for guidance on what to eat and how much.
The guidelines also offer a nice chart on on the differences in calorie intake from trimester to trimester and also for lactation. The differences in lactation calories are important to note. The first 6 months have a lower calorie intake than the second 6 months to encourage loss of pregnancy weight. Return to pregnancy weight should be gradual and this table should be used as a guide.
The Follow Up
Whew, we made it through all that information…but where do you go from here? The follow up information is just as important as the rest of the visit!
Here’s a list to review with a woman and her family before leaving the clinic!
- When is the next recommended appointment?
- Are any referrals needed?
- Genetic counselor
- Maternal fetal medicine
- Physical therapy
- Mental health counseling
- Social work
- Nutritionist (vegan, vegetarian, underweight/overweight BMIs, multiple gestation)
- Lactation consultant (prior breast surgery or breastfeeding concerns)
- Are any medical records needed?
- Encourage patient to request records as indicated
- Review upcoming laboratory testing
- Review upcoming ultrasounds
- Review need to pick up medications OTC or prescriptions
- Enroll in group prenatal care
- Are there any last questions or concerns?
For providers and women. the Share with Women Handouts cannot be beat for many discomforts and conditions of pregnancy. ACOG’s Resources for You (Frequently Asked Questions about pregnancy/women’s health) and Healthychildren.org‘s Prenatal Resources are also excellent resources.
For any recommendations about books to read during pregnancy, I like to start with these recommendations:
- Birth Matters by Ina May Gaskin
- A stark reminder of how birth should be and the interventions that often intrude into an otherwise normal process. An excellent read.
- Ina May’s Guide to Childbirth by Ina May Gaskin
- Excellent, heartfelt, REAL stories about natural labor and childbirth, with emphasis on minimal interventions and healthy body/mind connection for the woman, fetus/infant and family.
- Mindful Birthing: Training the Mind, Body, and Heart for Childbirth and Beyond by Nancy Bardacke
- My #1 recommendation to women asking for the book to help them successfully prepare for pregnancy, birth and postpartum (and beyond). If I could hand this book out at every new OB visit, I would.
- Natural Hospital Birth by Cynthia Gabriel
- An excellent resource for the mama that wants to deliver in the hospital but equally desires a natural birth.
- Real Food for Pregnancy by Lily Nichols
- Recommended by a blog reader!
- The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions by Penny Simkin
- Excellent read for any person planning support a woman in labor. My husband even read this while I was IN LABOR with my daughter.
These are some great online childbirth resources to recommend for the mama starting to look at education about labor and birth.
- FREE videos on epidural/spinal anesthesia, bathing your baby, soothing your baby, breastfeeding and postnatal pain
- Global Health Media – FREE videos on labor, postpartum, and breastfeeding!
- FREE videos on birth and childhood, produced by the United Kingdom and available in a number of different languages
These are some great podcast recommendations for pregnancy and parenting.
- Mother to Baby
- This podcast offers some education on common pregnancy conditions – for example, pre-eclampsia and intrahepatic cholestasis of pregnancy – but also offers information on if you can drink kombucha while you are pregnant! Consider subscribing to brush up on all the Q+As they offer. These would be great to listen to in the car on the way to and from OB appointments.
- Mother to Baby
- Parenting Podcasts
Whew! That’s a wrap. Remember, this is only a guide for the 16 week visit. Providers and patients work together to address the needs at the time of the visit. And, much of prenatal education is reviewed again and again!
The 16 week template is in the works!
What other topics do providers like to cover at 16 weeks? As a pregnant mama, what topics do you want covered? What podcasts or books do you all love and recommend?
Let me know!
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American Academy of Pediatrics, & American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care (8th ed.). DOI 10.1002/14651858.CD003519.pub3
American College of Obstetricians and Gynecologists. (2018). Screening for perinatal depression. Commitee opinion 757. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, Massachusetts: Jones & Bartlett Learning.