The 28 Week Visit



Happy Monday! Did you see the 28 week template went live over the weekend?? (This is Jamie doing a little happy dance).

Orange is not my favorite color. But I was really crushing on this template while I was putting the final touches on it. Hope you guys love it as much as I do. I can’t wait to use it in clinic.

Sidebar, I’ve been using these in clinic so much and they really help to hit all of the education points for each visit. If I can’t squeeze it all in, I encourage the mama to read it at home on her own. And if needed, I circle some website on the back for her to read up on some extra education or to find out more about the particular items she has more questions about.

Mama by mama, provider by provider, we’re making prenatal care better.

If you’re new to the series, here’s the goal. The point of this series is two-fold:

  1. Provide evidence-based education tailored to the gestational age of each prenatal visit.
  2. Offer a tool to guide the mama/family (and provider) through the visit components while simultaneously provided the woman a summary of her visit, pertinent education, and a list of additional resources to review at home.

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 28 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!
  • 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)
  • *Lab work for for gestational diabetes and anemia and vaccination for TDaP (and Rhogam) are typically accomplished at this visit as well

Let’s break it down!


Review of symptoms or patient concerns

These are symptoms that have occurred since the last visit that the patient desires to discuss with the provider. Here’s an example: “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.

  • 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 28 week visit:

  • What questions do you have about breast pumps?
  • What questions do you have about coping with labor pain?
  • Who are you planning to have at your birth?
  • What questions do you have about childbirth?
  • Have your family members been vaccinated against pertussis, flu or COVID?
  • Do you have a history of depression, anxiety or postpartum depression or anxiety?

The Screening

Screenings are usually completed in a number of fashions – sometimes by the tech asks the woman questions or the woman fills 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


Exam

Once the pregnancy is established, the exam is limited to checking for normal progression of the pregnancy.

Source
  • 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, lowest in the second trimester and then it rises again in the third 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 28 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 28 week mamas, you can at least palpate where the baby’s head is (Superville & Siccardi, 2021)! You can read all about the maneuvers here.
Laboratory testing

There are two labs done at this visit. The first is a screening for gestational diabetes. This test is usually a drink with high levels of sugar that is consumed in 5 to 10 minutes. Approximately 1 hour after you finish the drink, a lab blood draw is completed to test the value of glucose in your blood. At the same time, a second

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.

More information from ACOG about routine tests in pregnancy is available here.

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:

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).

*If your blood type is Rh negative, an antibody screen is also ordered (this is only done for mama’s with Rh negative blood or with a prior abnormal antibody level form their initial OB visit). Read more about Rh negative blood types here: Rh-Negative Blood Type and Pregnancy

Ultrasound

For the anatomy scan…Read all about the scan on the 20 Week Visit in case you missed it!

At this point, ultrasounds are either completed for assessment of growth, blood flow to/from the baby (also know as dopplers) or as follow up (if the placenta was close to the cervix or some anatomy pictures weren’t seen clearly in a prior scan).

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 Education

The 28 week visit is a welcome mat to the third trimester.

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!


anemia

Anemia is defined as a lower amount of red blood cells in your body. Red blood cells are important because they carry oxygen to the cells in your body. During pregnancy your body needs extra blood to transfer nutrients and oxygen through the placenta to the baby. Your baby also needs iron stores to make their own blood (American College of Nurse-Midwives [ACNM], 2018).

The most common causes of anemia during pregnancy and postpartum periods are iron deficiency anemia or blood loss. Iron deficiency anemia is also associated with low birth weight infants, preterm delivery and perinatal mortality (stillbirths and early deaths in infants) (AAP & ACOG, 2017).

The treatment for iron deficiency is 60 to 120mg of iron daily. Iron is absorbed in two ways – either by taking iron supplements or by increasing the iron in your diet (or both!) (AAP & ACOG, 2017). Iron’s main side effect is discomfort to your stomach or GI tract. It can cause cramping, nausea and constipation. Taking your iron with some food can help reduce the discomfort and taking a stool softener can help reduce constipation as long as you are taking iron.

After you have the baby, iron is still very important. Childbirth has a normal amount of bleeding associated with it whether you have a vaginal delivery or a cesarean section. Your body will replenish the lost blood but it takes a few weeks to a few months to replace the lost blood and the back up iron stores. Your cells need oxygen for healing after childbirth just as much as they need oxygen during the pregnancy!

Additional information about anemia is here:


gestational diabetes

Diabetes is a condition in which the body does not make enough insulin. When the body does not have enough insulin, the body struggles to use the food you eat for energy and there is a build up of extra sugar in your blood (CDC, 2020). Gestational diabetes is diagnosed when a woman without a history of diabetes develops diabetes during pregnancy.

Some women are at increased risk for gestational diabetes.

Risk factors include:

  • Being overnight or obese
  • Being physically inactive
  • Having a prior pregnancy with gestational diabetes
  • Having a large baby
  • Having high blood pressure
  • A history of heart disease
  • Having polycystic ovary syndrome (ACOG, 2020)

Regardless of risk factors, all pregnant women should be screened for gestational diabetes between 24 to 28 weeks. The screening test is called a 1 hour glucose tolerance test and is completed by drinking a glucola drink. After 1 hour, blood is drawn to check the level of the woman’s glucose. Fasting is not required for test completion (AAP & ACOG, 2017). 

If the 1 hour test is elevated, a 3 hour test is recommended. The 3 hour test is considered diagnostic and, if 2 out of 4 values during the test are abnormal, a women is diagnosed with gestational diabetes.

Diabetes management during pregnancy consists of nutrition counseling, daily blood sugar testing, exercise and more frequent ultrasounds and provider visits. Most diabetes in pregnancy can be controlled with your diet, but some women do need medication to help regulate their glucose levels.

More information about gestational diabetes can be found here…


doula support

Doulas are trained in pregnancy, birth and postpartum support for women and families. 

During labor and birth, doulas provide continuous emotional and physical support and coordinate interventions for pain (position changes, breathing, relaxation, comfort measures), while simultaneously encouraging informed consent each step of labor. 

Doula care has been associated with shortened labors, reduced need for pain medication, reduced need for pitocin, fewer operative births or cesarean sections and higher satisfaction with labor (AAP & ACOG, 2017; DONA, 2012). 

Doulas are generally employed independently or work with a hospital system or group practice. Most doulas charge a flat fee. Insurance coverage varies. 

Doulas are generally booked in advance of the birth, so if you are considering doula care, reach out to doulas in your community to find out more information about the services that offer!

More information is available here:

Watch this video to see a doula in action…


Exercise benefits for labor, birth and postpartum

Hopefully exercise is a good habit at this point. But sometimes, a pregnancy is fraught with nausea and vomiting and energy levels are low. Even a simple walk every day is beneficial for mental and physical health in pregnancy.

Safe exercises in pregnancy include: walking, stationary cycling, aerobic exercise, dancing, resistance exercise with weights or resistance bands, stretching, and water aerobics. 

Regular exercise in pregnancy is associated with a higher incidence of vaginal delivery and a lower incidence of too much weight gain, diabetes in pregnancy, high blood pressure in pregnancy, cesarean section, preterm birth and low birth weight (ACOG, 2020b).

Women that regularly exercise report fewer body aches and lower back or sciatica pain. Exercise has not been associated with an increased risk of preterm birth and regular exercise can improve postpartum recovery time after your birth (ACOG, 2020b). 

Kaiser Permanente has a nice video summarizing exercise in pregnancy!


trial of labor after cesarean

A trial of labor after cesarean (TOLAC) is when a woman with a prior cesarean birth desires to attempt a vaginal birth after cesarean (VBAC). 

60-80% of women who attempt a VBAC are successful!

A successful VBAC is associated with decreases in maternal mortality and fewer complications in future pregnancies Additionally, successful VBACs are associated with lower rates of hemorrhage or infection from avoidance of surgery, and a faster recovery time (AAP & ACOG, 2017; ACNM, 2011). 

The greatest risk for a TOLAC is called uterine rupture and occurs in 0.5-0.7% of women compared to 0.3% of women during an elective repeat cesarean section (ACNM, 2011). 

Conversations about TOLAC should start early in prenatal care and include a review of the woman’s concerns, the provider’s counseling and recommendation and a review of the available services offered at the hospital (AAP & ACOG, 2017).

More information about TOLACs is available here…


contraception

Contraception is a term to describe methods or medications to prevent pregnancy. Many women report that they do not know enough about the different types of contraception.

Based on a family planning survey conducted by the American College of Nurse-Midwives (2013) :

  • Women do not feel like they know enough information about the types of contraception available to them.
  • Many healthcare providers are not adequately educating and counseling women on how to use the method that they are prescribed.
  • 40% of women reported they were not given information on how to use the contraception method they were prescribed by their provider.
  • Women reported barriers such as long wait times to schedule appointments or difficulty talking with their provider that made it difficult to manage side effects or ask about changing their method.
  • Women has misconceptions about which method of contraception may be harmful to them.
  • Many women are not using the contraception methods that are the most effective at preventing pregnancy (Johnson, Kane Low, Kaplan et al., 2013).

Types of contraception include: pills, patch, vaginal rings, patches, injection, subdermal arm implants, intrauterine devices, female or male sterilization, condoms, spermicides, diaphragms, sponges, withdrawal, lactation amenorrhea method, and natural family planning. 

Contraception counseling should include: a review of the most and least effective methods; correct use of the method; benefits or risks of method; side effects of method; and prevention of STDs (only condoms prevent STDs) (Gavin et al., 2014). It’s also important to consider the patient’s reproductive life plan (how many children are desired and how close together) and if the woman plans to breastfeed (some contraception methods are not recommended during breastfeeding).

The third trimester is an opportune time to discuss the methods available, how to use them and when the woman plans to start the method.

There are many tools for contraception counseling but I think these are the best out there:


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
  • 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 or breastfeeding, 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.
  • Making More Milk: The Breastfeeding Mother’s Guide by Diana West & Lisa Marasco
  • 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.
  • The Fourth Trimester by Kimberly Ann Johnson
    • An amazing book for any birth worker that is present during the postpartum window. Check out my review on the book here!
  • The Womanly Art of Breastfeeding by Marianne Neifert (La Leche League International)
    • My personal favorite for breastfeeding. Easy to find at a used bookstore or garage sale. I didn’t read this until my first was 6 months old and I wished I had read it before she was even born! It answered so many questions about breastfeeding after 6 months and nursing/sleeping changes with a babe!

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.

And this is a 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 28 week visit. Providers and patients should work together to address all patient 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 28 weeks? As a pregnant mama, what topics do you want covered at this point in pregnancy? And…the 28 week template is LIVE! Check it out here.

Let me know!

Jamie


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1 year ago on the blog…Friday Five (#29)

2 years ago on the blog…Friday Five (#8)


Links in the post

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

ACNM’s Preventing Iron Deficiency Anemia During Pregnancy: https://onlinelibrary.wiley.com/doi/10.1111/jmwh.12940

ACNM’s Rh-Negative Blood Type and Pregnancy: https://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000003906/Rh_negative_blood_pregnancy.pdf

Edinburgh Postnatal Depression Scale (EPDS): https://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf

Infographics for foods high in iron: here and here (vegetarians)

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

Royal College of Obstetricians & Gynaecologists (RCOG, 2020): https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-gestational-diabetes.pdf

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

TDaP Vaccination (ACOG): https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/09/update-on-immunization-and-pregnancy-tetanus-diphtheria-and-pertussis-vaccination

University of California – San Francisco’s Dietary Recommendations for Gestational Diabetes: https://www.ucsfhealth.org/education/dietary-recommendations-for-gestational-diabetes

University of California – San Francisco’s Counting Carbs: https://www.ucsfhealth.org/education/gestational-diabetes-counting-carbs

U.S. DHHS’s Managing Gestational Diabetes: https://www.nichd.nih.gov/sites/default/files/publications/pubs/Documents/managing_gestational_diabetes.pdf


References

American College of Nurse-Midwives. (2011). Vaginal birth after cesarean delivery. http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000090/VBAC%20Dec%202011.pdf

American College of Nurse-Midwives. (2019). Preventing iron deficiency anemia during pregnancy. Journal of Midwifery & Women’s Health, 64(1). doi: 10.1111/jmwh.12940

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 Nurse-Midwives. (2013). Family planning and birth control survey key findings. Our Moment of Truth: A New Understanding of Midwifery Care. http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000003464/2013%20ACNM%20Contraception%20Survey%20-%20Key%20Findings.pdf.

American College of Obstetricians and Gynecologists. (2018). Screening for perinatal depression. Committee opinion 757. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression

American College of Obstetricians and Gynecologists. (2020a). Gestational diabetes: Frequently asked questions. https://www.acog.org/womens-health/faqs/gestational-diabetes

American College of Obstetricians & Gynecologists. (2020b). Physical activity and exercise during pregnancy and the postpartum period. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/04/physical-activity-and-exercise-during-pregnancy-and-the-postpartum-period

Centers for Disease Control and Prevention. (2020). Depression among women. https://www.cdc.gov/reproductivehealth/depression/

Centers for Disease Control and Prevention. (2020). Pregnancy: Diabetes. https://www.cdc.gov/pregnancy/diabetes.html

DONA. (2012). Position paper: The birth doula’s role in maternity care. https://www.dona.org/wp-content/uploads/2018/03/DONA-Birth-Position-Paper-FINAL.pdf

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

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