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:
- Provide evidence-based education on the components of 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.
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 24 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 – there are upcoming lab tests and vaccines at the 28 week visit!
- 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 24 week visit:
- Are you taking any childbirth preparation classes?
- Are you planning on using a doula for birth?
- Are you planning a home birth?
- How are you sleeping?
- How is your appetite?
- What kind of exercise are you doing?
- Do you have any discomfort of pregnancy that is limiting you every day?
- Are you planning on breastfeeding? What do you know about breastfeeding?
- Do you have any travel planned before the baby’s due date?
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.
- 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. Typically, the fundal height is palpated up to 20 weeks. At 24 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 fetal heart rates are higher at the beginning of pregnancy.
- Leopold maneuvers
- This set of maneuvers was developed by a German obstetrician in the late 1800s and helps determine the baby’s position in the uterus. There are four moves that the provider performs by palpating the uterus in a methodical manner to see how the baby is positioned. In most 24 week mamas, you can at least palpate where the baby’s head is (Superville & Siccardi, 2021)! You can read all about the maneuvers here.
There are very few labs that are done around this visit.
If the anatomy scan was not reviewed at the 20 week visit, the report is typically reviewed at the 24 week visit.
Some high risk pregnancy disorders (chronic hypertension, diabetes, intrauterine growth restriction) continue to have regular ultrasounds throughout the pregnancy to assess the baby’s growth and well-being. Low risk pregnancies tend to only have the dating scan and the anatomy scan – but this varies greatly from practice to practice and city to city.
The 24 week visit is a sweet spot for education. You’re not quite into the bulk of the third trimester and you still have quite a bit of energy before the uterus really increases in size. I find that this time period is equally education for things that are current questions, issues or discomforts (back pain, traveling, mental health, or vaccines) or it’s a time to talk about about things that are right around the bend (28 week labs, vaccines (again), preterm labor and breastfeeding).
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!
When it comes to back pain in pregnancy, it’s usually not a matter of if, but when.
Back pain is extremely common in pregnancy. The pain is from a number of factors, but the root cause is an enlarged uterus. There are hormones in pregnancy that cause your ligaments to stretch and soften more easily than when you are not pregnant.
There are a number of interventions that you can try to reduce the discomfort:
- Sleep on your side.
- Get plenty of rest. Ensure that you are sleeping on a good, firm mattress.
- Use a heating pad or rice sock on areas of discomfort.
- Get a massage.
- Take a warm bath (use epsom salts!)
- Use a pregnancy support belt.
- Avoid lifting heavy objects. (Or learn to lift them properly!).
- Wear low heeled shoes.
- Balance weight when carrying shopping bags.
- Continue regular exercise throughout your pregnancy. Prenatal yoga is especially good for back pain in pregnancy.
- Stretch regularly during pregnancy. Try these stretches here and here.
The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend that children start breastfeeding within the first hour after birth and that breastmilk is the only source of food for the first six months of the baby’s life. At six months of age, infants should begin to eat food while continuing to breastfeed for up to two years, or as long as desired by mother and infant (World Health Organization, 2021).
Breastfeeding can provide a child half of a child’s nutrients (food) between the ages of 6 and 12 months and up to a third of nutrients from 12 to 24 months (World Health Organization, 2021).
Babies that are breastfed are:
- Less likely to be overweight or obese.
- More likely to perform better on intelligence tests or have higher school attendance.
- More likely to have higher incomes in life (World Health Organization, 2021).
Mothers that breastfeed are:
- Less likely to have ovarian and breast cancer (World Health Organization, 2021).
Babies that are not breastfed are:
- More likely to be obese.
- More likely to have type 1 or type 2 diabetes.
- More likely to have leukemia.
- More likely to have sudden infant death syndrome (Stuebe, 2009).
Mothers that do not breastfeed are:
- More likely to have premenopausal breast cancer.
- More likely to have ovarian cancer.
- More likely to keep weight gained in pregnancy.
- More likely to have type 2 diabetes.
- More likely to have a myocardial infarction (heart attack).
- More likely to have metabolic syndrome (Stuebe, 2009).
In the age of the Internet, there are some amazing websites about breastfeeding. These are some of my favorites:
Other great breastfeeding resources can be found under ‘breastfeeding’ on the RESOURCES page.
Preterm labor is defined as:
Regular contractions with cervical change before 37 weeks of age (ACOG & AAP, 2017) .
The pathophysiology behind preterm labor is still unknown. Possible causes of preterm labor include hemorrhage of the placenta (known as placental abruption), uterine over-distention (such as in twin pregnancies), cervical insufficiency (a short or dilated cervix), hormone changes, infection or inflammation (ACOG & AAP, 2017).
On of the biggest risk factors for a preterm birth is a prior preterm birth. Women that have had a preterm birth before are 1.5 to 2 times more likely to have another preterm birth (ACOG & AAP, 2017).
It’s important to review preterm labor signs and symptoms at second and third trimester visits. A woman should also have a phone number to contact a provider or nurse and a place to go for evaluation should she have any of the signs or symptoms (ACOG & AAP, 2017).
The signs and symptoms include (see infographic above):
- Regular contractions (painful or not painful)
- Constant, dull low backache
- Belly cramps with or without diarrhea
- A feeling that the baby is pushing down
- Change in vaginal discharge or more discharge than normal
- Your water breaks (March of Dimes, 2018)
This March of Dimes video offers a great overview of preterm labor signs…
travel during pregnancy
Cohort studies have shown that air travel in pregnancy is not associated with adverse outcomes. Domestic travel up to 36 weeks of gestation is generally allowed by airlines but internal airlines may have different guidelines. The most common emergencies in pregnancy occur in the first and third trimesters (ACOG & AAP, 2017).
Air travel is not recommended for any pregnant woman that has medical or pregnancy conditions that could worsen from air travel or that may require emergency care (ACOG & AAP, 2017).
Women that travel by air or take long road trips should:
- Use support stockings
- Take frequent breaks to stretch and walk around
- Avoid restrictive clothing
- Stay hydrated by drinking plenty of fluids (ACOG & AAP, 2017).
Zika is the only mosquito borne illness that has been associated with birth defects in infants. Birth defects from Zika include microcephaly (a small head) and brain abnormalities. Pregnant women should avoid travel to areas with Zika; if unable to avoid such areas, women should use insect repellant with DEET, wear clothing that covers the skin, and attempt to stay in air conditioned or screened in areas. ACOG and the CDC (Centers for Disease Control and Prevention) also recommend treating clothing with permethrin (ACOG & AAP, 2017).
If your spouse travels to an area with Zika, the CDC recommends either abstinence from intercourse or condom use during the woman’s pregnancy (ACOG & AAP, 2017).
Regarding COVID-19, the most up to date precautions for travelers are here.
About 1 in 10 women reported an episode of depression in the past year (Centers for Disease Control and Prevention [CDC], 2020).
About 1 in 8 women experience symptoms of postpartum depression (CDC, 2020).
ACOG recommends that women be screened for depression at least once during the prenatal period (ACOG & AAP, 2017). Many clinics screen more often but screenings do vary from clinic to clinic and practice to practice. Most clinics use a validated depression screening called the Edinburgh Postnatal Depression Scale or an EPDS.
This screening produces a score that allows a provider to see if a woman screens positive for mild, moderate or severe depression.
Depression can consist of a few symptoms or a lot of symptoms. Symptoms of depression can include:
- Long lasting feelings of sadness, anxiety or emptiness
- Feelings of hopelessness
- Feelings of pessimism
- Feelings of guilt, worthlessness or helplessness
- Loss of interest in normal hobbies
- Loss of energy
- Difficulty concentrating, remembering details or making decisions
- Trouble sleeping or sleeping too much
- Eating too much food or loss of appetite
- Thoughts of harming yourself or suicide (CDC, 2020)
There are lots of risk factors for depression or anxiety. Sometimes, you may start your pregnancy with some risk factors. Sometimes, you may start your pregnancy without any risk factors, but then your partner loses their job, you move across the country and you have a traumatic delivery. All of these risk factors increase your risk for postpartum depression or anxiety.
Not sure if you have risk factors? Start with this tool by Postpartum Support International! You can print it out, fill it out, and take it into your provider to review together at a visit. The resources are all free and you can access them all from your couch!
Do you already have depression, anxiety or other mental disorders?
28 week labs and recommended vaccines
A glucose and an anemia screening are recommended around 28 weeks of pregnancy. The glucose test is a screening for gestational diabetes and the anemia screening is exactly that – a screening to make sure you are not deficient in iron or have another type of anemia.
The glucose test is a sugary drink generally provided by the lab or the office staff. The drink is 50 grams of glucose. The woman has about 10 minutes to drink the bottle (they usually taste like orange, red or yellow gatorade flavors). About an hour after she finishes the bottle, a blood sample is taken to check your blood sugar level. If you level is abnormal, or high, a follow up test is recommended.
The follow up test is a 3 hour test with a 100 gram drink. The 3 hour glucose test is considered the diagnostic test for gestational diabetes – this means that if your 3 hour test is abnormal, you will likely receive the diagnosis of gestational diabetes in pregnancy.
At 28 weeks, the TDaP vaccine (tetanus-diptheria-pertussis) is recommended for pregnant women. The actual range for the vaccine is between 27 to 36 weeks. When the vaccine is given during this time, the mother’s immune system creates antibodies in response to the vaccination and these antibodies are transferred across the placenta to the baby (CDC, 2021).
The vaccine reduces the risk of a baby less than 2 months old from getting whooping cough by 78% (CDC, 2021).
TDaP vaccination for pregnant women is supported by a number of profession organizations. You can read their statements of support here:
- American College of Obstetricians and Gynecologists
- American College of Nurse-Midwives
- American Academy of Pediatrics
- American Academy of Family Physicians
Lastly, it is not routine to test the number of antibodies a woman has to whooping cough and it is not known what level of immunity is protective against whooping cough. Because of this, a TDaP vaccine is recommend during every pregnancy – even if your pregnancies are only one to two years apart (CDC, 2021).
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
- 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.
For any recommendations about books to read during pregnancy, I like to start with these recommendations, but a full list is available on the BOOKS & MORE page!
- Babies are Not Pizzas: They’re Born, Not Delivered by Rebecca Dekker
- This was my favorite read of 2021. It should be mandatory reading for all birth providers and everyone involved in birth work. Rebecca talks candidly about the obstetric healthcare system, obstetric violence, evidence based birth and the need to change the culture of obstetric care. Rebecca is also the founder of evidencebasedbirth.com
- 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.
- Global Health Media – FREE videos on labor, postpartum, and breastfeeding!
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
And this is great blog for new mamas to follow on topics regarding your baby’s health…
Whew! That’s a wrap. Remember, this is only a guide for the 24 week visit. Providers and patients work together to address the needs at the time of the visit. And, a lot of prenatal education is reviewed again and again!
What other topics do providers like to cover at 24 weeks? As a pregnant mama, what topics do you want covered at the midway point through pregnancy? And…the 24 week template is LIVE! It’s so pretty in purple. Check it out here.
Let me know!
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Links in the post
ACOG’s Resources for You: https://www.acog.org/womens-health/resources-for-you
Back Pain in Pregnancy (NHS): https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/back-pain/
COVID-19 and Travel: https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html
Edinburgh Postnatal Depression Scale (EPDS): https://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
Perinatal Mental Health Discussion Tool: https://www.postpartum.net/wp-content/uploads/2019/05/PSI-Perinatal-Mental-Health-Discusion-Tool.pdf
Postpartum Support International’s Weekly Support groups: https://www.postpartum.net/get-help/psi-online-support-meetings/
Pregnancy and Whooping Cough (CDC): https://www.cdc.gov/pertussis/pregnant/mom/get-vaccinated.html
Routine Tests in Pregnancy: https://www.acog.org/womens-health/faqs/routine-tests-during-pregnancy
Share with Women handouts: http://www.midwife.org/Share-With-Women
Signs and Symptoms of Preterm Labor (March of Dimes): https://www.marchofdimes.org/complications/signs-and-symptoms-of-preterm-labor-infographic.aspx
Travel during Pregnancy (ACOG): https://www.acog.org/womens-health/faqs/travel-during-pregnancy
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
Centers for Disease Control and Prevention. (2020). Depression among women. https://www.cdc.gov/reproductivehealth/depression/
King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, Massachusetts: Jones & Bartlett Learning.
National Health Service. (2021). Back pain in pregnancy. https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/back-pain/
Cedars-Sinai. (2021). Back pain during pregnancy. https://www.cedars-sinai.org/health-library/diseases-and-conditions/b/back-pain-during-pregnancy.html
Journal of Midwifery & Women’s Health. (2005). Back pain during pregnancy. http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000000624/Back%20Pain%20During%20Pregnancy.pdf
Postpartum Support International. (2021). Perinatal mental health discussion tool. https://www.postpartum.net/wp-content/uploads/2019/05/PSI-Perinatal-Mental-Health-Discusion-Tool.pdf
Postpartum Support Virginia. (2020). Path to wellness. https://postpartumva.org/wp-content/uploads/2020/11/PSVA_PathToWellness_090820.pdf
Stuebe, A. (2009). The risks of not breastfeeding for mothers and infant. Obstetrics & Gynecology, 2(4), 222-231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/
Superville, S., & Siccardi, M. (2021). Leopold maneuvers. https://www.ncbi.nlm.nih.gov/books/NBK560814/
World Health Organization. (2021). Breastfeeding. https://www.who.int/health-topics/breastfeeding#tab=tab_2