The 20 Week Visit


We’re continuing our series on routine prenatal care around here! 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:

  1. Provide evidence-based education on the components of each prenatal visit.
  2. 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.

In case you missed the other posts so far…here are the links!

The templates are always available for download on the TOOLS & HANDOUTS page – and they’re free to share!

What are the components of the 20 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
  • Reassurance
  • 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?

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 20 week visit:

  • Do you have any upcoming travel plans?
  • How are you sleeping?
  • What kind of exercise are you doing?
  • Do you have any back or pelvic pain? Any round ligament pain?
  • What are your plans for education about pregnancy and childbirth?

The Screening

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

Source

Exam

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.
Laboratory testing

Lab testing at the 20 week visit 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!

Ultrasound

The 20 week visit is eagerly anticipated because this visit usually involves an anatomy ultrasound. This is often the first time for a mama to find out the gender of her babe!

An anatomy ultrasound is recommended for every pregnancy. In the absence of indications to do additional ultrasounds, the best time to perform a single ultrasound is between 18 to 22 weeks (AAP & ACOG, 2017).

The anatomy ultrasound is named appropriately – the sonographer looks at the anatomy of the fetus, the placenta, the uterus and the ovaries. And it’s not just a general look, there are very specific guidelines to examine during the ultrasound. The specifics are here if you want to read the practice guideline from the Journal of Ultrasound Medicine.

Most providers are looking for a few key things:

  • The anatomy of the baby looks normal
  • The baby’s growth is normal (greater than 10th percentile)
  • The amniotic fluid level is normal
  • The placenta appears normal and is not near, or on top of the cervix
Source

Sometimes the babies are little wiggle worms or very stubborn (i.e., they stay in the same position the whole ultrasound) and it is hard to get a good image of the anatomy. In these cases, the radiologist will recommend a repeat ultrasound to look at the anatomy again. Another common reason to recommend an additional ultrasound is if you have a low lying placenta, or a placenta within 2 centimeters of the cervix. For these placentas, it’s important to ensure they move away from the cervix so that the mother is able to have a vaginal birth. Most of the time, these placentas move, but they move slowly. Commonly, an anatomy ultrasound will note a low lying placenta and another ultrasound is repeated in the third trimester (2-3 months later) to see where the placenta location is.


The Education

The is so much education to offer at 20 weeks. Women aren’t nauseous or vomiting. Naps are common. Back pain can start to increase. Exercise is easy for some women in pregnancy but difficult for others. Fetal movement is starting and slowly increases each day. These are the common areas of education, but the sky really is the limit and varies greatly from provider to provider.

These are the ones that I think are best for the gestational age!

Fetal Movement

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!

At 20 weeks, even if a mama has felt her baby move, it’s important to continue the information about what she can continue to expect up until the next prenatal visit.

Round ligament pain

Most women have had some round ligament pain by their 20 week visit, but many don’t know 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.

Source

Some good handouts for round ligament pain are here and here.

Stretches and interventions for round ligament pain are the same for most of pregnancy – so something that helped at 16 weeks will continue to help at 20 weeks or 24 weeks.

leukorrhea and vaginitis

Vaginal discharge is inevitable during pregnancy. Some of the discharge is normal and some of it can be an infection. Here’s a recap of what to expect from the vagina…and what not to!

The vagina begins to produce a normal watery discharge after puberty that contains microorganisms. This discharge helps keep the vagina clean and removes dead cells from the vagina.

The amount of vaginal discharge that you have can change throughout pregnancy. For example, you might have a little discharge in the beginning of pregnancy and more discharge in the last trimester. Some women have so much (normal) discharge that they wear a peripad during their pregnancy.

The vagina is full of bacteria. When the bacteria in the vagina are disrupted, a vaginal infection can occur. Vaginal infections are more common in pregnancy. Vaginal infections are most often a yeast infection (yeast vaginosis) or bacterial vaginosis. Or sometimes they are called vulvovaginitis (ACOG, 2021).

Yeast infections are not harmful to the mother or the baby, but they can cause considerable itching and bothersome discharge. Bacterial vaginosis can increase a woman’s risk for preterm labor., premature rupture of membranes and infection in the uterus/amniotic sac Therefore, when bacterial vaginosis is diagnosed, the recommendation is to offer treatment. Sometimes a vaginal discharge can be a sexually transmitted disease.

You can read more here…

This is also a great chart about STDs and pregnancy. (See below).

Source

A good rule of thumb is that any change in vaginal discharge warrants evaluation by your provider!

Sleep

Nausea, vomiting, increased heart rate, shortness of breath, heartburn, frequent urination, and leg cramps are common disruptors of sleep in pregnancy.

By 20 weeks gestation, most woman have a small bump that has altered their normal sleep habits in some form or fashion,

Here are some tips to improve your sleep include:

  • Keep your bedroom cool, dark and quiet
  • Go to bed at the same time each night
  • Use support pillows (this could be an extra pillow or a pregnancy pillow)
  • Read a book before bed
  • Take naps early in the day if needed
  • Avoid caffeine, heavy meals or spicy food prior to bed
  • Avoid screens in the bedroom
  • Exercise early in the day
  • Drink plenty of water during the day but reduce water after dinnertime to limit bathroom trips at night time
  • Use a sound machine or fan for white noise (this helps the baby sleep too after birth!)
  • If you’re not sleepy, do an activity out of bed until you are sleepy (Sleep Foundation, 2020)

Good sleep habits will help you feel more rested and stronger during your pregnancy. These habits will set a strong foundation for your postpartum period too!

REDUCE YOUR BABY’S RISK OF ALLERGIES

I posted on this a while back but realized that if we aren’t intentional about talking about this during prenatal care, it’s not something that’s just going to come up in prenatal visits.

What’s a surefire way to bring this up more often? Put it on the templates.

Here’s the background:

Twenty years ago, the United Kingdom’s medical officer for Toxicity of Chemicals in Food made a poor recommendation. The officer recommended that mothers without a peanut allergy should avoid consumption of peanuts and products containing peanuts to avoid a peanut allergy in their baby. Well, that sounded like a good idea. The problem is that when a mother eats her body makes an immune response to that food, something called immunoglobulins, and these immunoglobulins pass through the placenta and to the baby during pregnancy (Fujimara et al., 2019).

The result of the medical officer’s recommendation to avoid peanuts during pregnancy resulted in the highest prevalence of peanut allergies in 4 to 5 year old children. Avoidance was causing more harm than good (Fujimara et al., 2019).

What evidence is there for a protective effect when pregnant mamas eat certain foods while pregnant or breastfeeding?

  • A study of 6,288 children in Finland demonstrated that eating/drinking milk products in pregnancy resulted in a lower risk of an allergy to cow’s milk in mothers not allergic to milk (odds ratio: 0.30; this means in this study, the mothers than ingested cow’s milk were 70% less likely to have a child with a milk allergy because they ingested milk during their pregnancy). This specific study found immunoglobulin A in the cord blood samples of children who did not have milk allergies. This finding supports that the maternal ingestion of milk helps produce an immune system response during pregnancy that protects the child from a future milk allergy (Fujimara at al, 2019).
  • A study of 8,205 children between 10 to 14 years old found that children of the mothers who ate peanut or tree nuts at least 5 times a week during pregnancy were 69% less likely to have a peanut allergy. An important note in this study was there was not a protective effect observed in mothers who were already allergic to peanuts or tree nuts. The reduction in peanut or tree nut allergy risk was only noted in pregnant women not previously allergic to peanuts or tree nuts (Fujimara et al., 2109).
  • A cohort study in the United States examined 1,277 mother-child pairs and found a number of factors that reduce allergy and asthma in children. This study in particular demonstrated that early exposure to allergens in the first or second trimester of pregnancy may contribute to tolerance rather than contribute to allergy development in children.
    • Ingestion of peanuts in the first trimester by pregnant women was associated with a 47% less likelihood of peanut allergy in the child.
    • Ingestion of milk during the first trimester was associated with a 17% less likelihood of asthma and a 15% less likelihood of allergic rhinitis.
    • Ingestion of wheat in the second trimester was associated with a 36% less likelihood of atopic dermatitis (Fujimara et al., 2019).
  • Breastfeeding mothers who consumed peanuts while breastfeeding and who introduced peanuts to their child before 12 months of age had reduced incidence of peanut allergy in their children (only 1.7% of population demonstrated a peanut allergy). Mothers that waited until their child was older than 12 months or avoided peanuts altogether had a 15.1% and a 17.6% increased risk of peanut allergy in their children (Fujimara et al., 2019).

If you are a woman with an allergy to peanuts, there is good news as well. The LEAP trial, a randomized controlled trial published in the New England Journal of Medicine in 2015, found that introducing peanuts to infants at higher risk for peanut allergy reduces the incidence of peanut allergy (Fujimara et al., 2019)! You can check out the LEAP study here. The study is currently looking at how long children have immune protection after exposure to peanuts and if there are other parent characteristics that could contribute or impact peanut allergy development.

Dietary supplements can also contribute to lower likelihood of asthma in childhood. Two studies (Vitamin D Antenatal Asthma Reduction Trial and the Copenhagen Prospective Studies on Asthma in Childhood) have examined Vitamin D supplementation during pregnancy and found that children of women who ingested 2,400 to 4,000 international units of Vitamin D daily during pregnancy had a 25% reduced risk of developing asthma or recurrent wheezing from ages 0 to 3 years (Fujimara et al., 2019).

Maternal intake of fish oil supplements or a diet of oily fish has been shown to offer protective effects against asthma and wheezing in children, as well as a reduction in atopic eczema and allergy to eggs.

Based on the evidence, and without a contraindication in the woman’s history or allergies, I think it’s safe to recommend nuts, milk and wheat in most pregnancies. It’s at least worth reviewing the education for the woman to make her own decision!

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
    • Chiropractor
    • 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?

Other goodies…

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:

These are some great online childbirth resources to recommend for the mama starting to look at education about labor and birth.

These are some great podcast recommendations for pregnancy and parenting.


Whew! That’s a wrap. Remember, this is only a guide for the 20 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!

What other topics do providers like to cover at 20 weeks? As a pregnant mama, what topics do you want covered at the midway point through pregnancy?

And…the 20 week template is LIVE! It’s so pretty in purple. Check it out here.

Let me know!

Jamie


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Links in the post

ACOG’s Resources for You: https://www.acog.org/womens-health/resources-for-you

AIUM Practice Parameter for the Performance of Detailed Second- and Third-Trimester Diagnostic Obstetric Ultrasound Examinations: https://onlinelibrary.wiley.com/doi/10.1002/jum.15163

Bacterial vaginosis (CDC): https://www.cdc.gov/std/bv/BV-FS.pdf

Bacterial vaginosis (March of Dimes): https://www.marchofdimes.org/complications/bacterial-vaginosis.aspx

How to Introduce Peanuts to Your Baby: https://aafacenters.com/early-introduction-of-peanut/

LEAP study: http://www.leapstudy.co.uk/

MEDLINE Plus: Vaginitis: https://medlineplus.gov/vaginitis.html

Pregnancy and Sleep: https://www.sleepfoundation.org/pregnancy

Share with Women handouts: http://www.midwife.org/Share-With-Women

STDs during Pregnancy – CDC Fact Sheet (Detailed): https://www.cdc.gov/std/pregnancy/stdfact-pregnancy-detailed.htm

Yeast infections: https://www.womenshealth.gov/a-z-topics/vaginal-yeast-infections

Your Baby’s Movements (RCOG): https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-your-babys-movements-in-pregnancy.pdf


References

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

American College of Obstetricians & Gynecologists. (2021). Vulvovaginal health. https://www.acog.org/womens-health/faqs/vulvovaginal-health

Fujimara, T., Zing Chin Lum, S., Nagata, Y., Kawamoto, S., & Oyoshi, M.K. (2019). Influences of maternal factors over offspring allergies and the application of food allergy. Frontiers in Immunology, 10. doi: 10.3389/fimmu.2019.01933

King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, Massachusetts: Jones & Bartlett Learning.

Sleep Foundation. (2020). Pregnancy and sleep. https://www.sleepfoundation.org/pregnancy

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