What Happens At My 32 Week Visit?



HUMP day and new template day! This template has so many resources on it, I don’t even know where to begin. I tried to detail everything below, but you’ll just have to check it out for yourself.

I also added a section for recommended books. Here’s the why: I was following trends of what I continually write down on sticky notes and paper towels for patients in clinic and books were one of the main things I remembered! I must write down 10 books per week between the postpartum units and the clinic. And while perusing Grow Midwives’ Resource page, I stumbled upon their “How to Have a Safe Birth” infographic. The #1 tip they offer is to read evidence-based books. I couldn’t’ agree more.

I also switched up the additional pregnancy education links. The links are active on the site so I took away the hyperlinks on the template.

Let me know what you think!

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)

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. These are some of the questions I ask at the 32 week visit:

  • What is your plan for pain management during labor?
  • What do you know about laboring at home?
  • What do you envision for your birth? Are you interested in writing a birth plans?
  • Were you able to procure a breast pump? What questions do you have about supplies needed for breastfeeding?
  • What do you know about the golden hour?
  • What do you know about the psotpartum period?
  • For multips, what were the results of your GBS swab in your prior pregnancy(ies)?

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 32 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 32 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

Usually, there are not any labs done at the 32 week visit unless 28 week labs were missed or are completed late. Read more about 28 week labs here.

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 32 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! And regarding the golden hour, although it may be early to start talking about these components of birth, remember that about 10% of births are preterm. So the 32 or 34 week visit may be the last visit the woman has before she goes into labor.


THE GOLDEN HOUR

The Golden Hour is the first hour after the baby is born. These five actions improve bonding, help your baby regulate temperature, and reduce stress levels in the baby and mother:

  • Delayed cord clamping
  • Placing the infant on the mother’s direct skin after birth for at least one hour
  • Completing baby assessments while skin to skin
  • Initiating breastfeeding
  • Delaying other interventions until later (bathing, weighing the baby) (Neczypor & Holley, 2017).

Some videos about skin to skin are below (these little newborn snuggles are my absolute favorite to watch!):


Make Your Birth Plan

A birth plan is a written set of desires and expectations for a woman and her family during her labor, birth and postpartum period.

Only one systematic review has examined birth plans. The review looked at 3 trials (n=1132 women) and noted that there was not enough evidence to show that a birth plan can improve the birth experience or satisfaction associated with birth.

These sites offer birth plan templates:

Don’t feel limited by these templates. You can also create your own!

Read more about limiting interventions during labor and birth here (ACOG, 2019).

Whatever method you choose, it is important to review the plan with the provider during your prenatal care and on admission to your birthing unit.

Talking about your birth plan during your prenatal care helps you and and your partner to make informed decisions (this is also known as shared decision-making) while simultaneously building a foundation of trust (DeBaets, 2016).


make your postpartum plan

It’s hard to cover all of this in a post. In fact, to cover everything might actually be a 2 day conference over a weekend. Alas, this will have to do. Consider this a bird’s eye view and dive down to whatever may interest you. For first time mamas, more research and reading might be indicated, but seasoned mamas may just need a quick scan of resources.

I posted a book review on The Fourth Trimester in 2021. Much of what was said in that post is true here.

To start, when you make a postpartum plan, consider these five needs during a postpartum period: an extended rest period, nourishing food, loving touch, the presence of wise women and spiritual companionship and contact with nature (Johnson, 2017).

Know that you are going to be sleep deprived. Sleep deprivation drives a lots of the planning to dos. But the planning really makes all of the difference.

Also consider these tips:

  • Plan to limit your screen time (screen time can complicate sleep patterns and the mental break that our mind needs).
  • Plan your nursing station (preferably near a window or a nice view); put a basket next to your station with blankets, burp clothes, nursing pads, a haakaa, a book or Kindle for you to read, a heating pad, nursing pillow and a blanket.
  • Make yourself a postpartum basket in your bathroom with pads, tucks pads, epsom salts…
  • Review warning signs to watch for in pregnancy and 1 year after birth: Hear Her Concerns.
  • Book recommendations: The Fourth Trimester by Kimberly Ann Johnson (2017)
  • Other resources: The 4th Trimester Project; The Blue Dot Project; Postpartum Support International; Postpartum Education for Parents

Postpartum Support Virginia’s My Family Postpartum Plan (in Spanish here) does a great job at walking women and their families through each of those five needs and more.

After a basic plan, there are a number of great resources to review.

Planning for this period really does help. It deserves as much attention as planning for the birth!


prepare for breastfeeding

There are some amazing educational opportunities on the web to learn about breastfeeding. These are my favorites:



prepare for birth

Preparing for birth takes a number of months. And it’s best to prepare one thing at a time if you can. With the pandemic, childbirth classes took a sideline. This list is meant to get you started.

  • Take a tour of your labor and delivery unit (in person or virtual).
  • Take a class about what to expect during childbirth. Or try these this free online class from Tucson Medical Center.
  • Read about Evidence Based Birth.
  • Read about Lamaze.
  • Learn your hospital’s visitor and mask policies while you are inpatient.
  • Pack your hospital bag. (Don’t forget your heating pad and snacks!)
  • Install the car seat. Find a place to get your car seat inspected here.
  • Make a plan for childcare for other children or members of your household, and for any pets you may have. Plan to have help for 2-3 days if needed.
  • Make some meals/soups for your freezer for easy meals when you come home from the hospital. Try these books for some great freezer meals.
  • Watch The Period of Purple Crying and the 5 S’s by Dr. Harvey Karp.
  • Know where to go or who to call when labor symptoms begin.

Remember too, that about 10% of births occur preterm (less than 37 weeks gestation). So get a head start if you are able or catch up as you can!


what to expect with GBS!

About 1 in 4 women carry a bacteria called GBS (group beta streptococcus) in their body.

Newborn babies are at risk to develop GBS. In the United States, about 2,000 babies get early or late onset GBS disease in the newborn period each year.

Pregnant women are screened for GBS between 36 and 37 weeks of pregnancy.

If a women tests positive for GBS, antibiotics are given during labor to prevent early onset disease. Antibiotics only work during labor.

If a pregnant woman that is GBS positive receives antibiotics in labor, the baby only has a 1 in 4000 chance of developing GBS disease. If antibiotics are not received in labor, the baby has a 1 in 200 chance of developing GBS disease.

The test is completed with a swab of the vagina AND the anus. Either the provider or the patient can collect the swab. See how the swab is collected here (CDC, 2020).


The Follow Up

Whew, we made it through all that information! All of those great sources live permanently on the RESOURCES and BOOKS pages.

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 Official Lamaze Guide: For a Healthy Pregnancy & Birth by Judith Lothian
  • 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 32 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 32 weeks? As a pregnant mama, what topics do you want covered at this point in pregnancy? And…the 32 week template is LIVE! Check it out here.

Let me know!

Jamie


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1 year ago on the blog…A Must Have Handout for Your Birth Plan and Your Birth Team

2 years ago on the blog…Women Ask Wednesday – The Well Woman Visit


Links in the post

5 S’s by Dr. Harvey Karp

ACOG’s Approaches to Limit Interventions during Labor and Birth: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth

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

Birth plan templates: March of Dimes; The Bump; Writing a Birth Plan

Perinatal Mental Health Discussion Tool: https://www.postpartum.net/wp-content/uploads/2019/05/PSI-Perinatal-Mental-Health-Discusion-Tool.pdf

Postpartum resources: The 4th Trimester Project; The Blue Dot Project; Postpartum Support International; Postpartum Education for Parents

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

The Period of Purple Crying

Tucson Medical Center (free birthing class, online)


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

Centers for Disease and Control and Prevention. Group b strep. https://www.cdc.gov/groupbstrep/about/fast-facts.html#:~:text=About%201%20in%204%20pregnant,onset%20GBS%20disease%20in%20newborns

DeBaets, A.M. (2016). From birth plan to birth partnership: Enhaving communication in childbirth. American Journal of Obstetrics & Gyneoclogy, 216(1), P31.E1-31.E4. doi: 10.1016/j.acog.2016.09.087

Hidalgo-Lopezosa, P., Cubero-Luna, A. M., Jiménez-Ruz, A., Hidalgo-Maestre, M., Rodríguez-Borrego, M. A., & López-Soto, P. J. (2021). Association between Birth Plan Use and Maternal and Neonatal Outcomes in Southern Spain: A Case-Control Study. International journal of environmental research and public health, 18(2), 456. https://doi.org/10.3390/ijerph18020456

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

Johnson, K.A. (2017). The fourth trimester: A postpartum guide to healing your body, balancing your emotions, and restoring your vitality. Shambhala.

Mirghafourvand, M., Mohammad Alizadeh Charandabi, S., Ghanbari-Homayi, S., Jahangiry, L., Nahaee, J., & Hadian, T. (2019). Effect of birth plans on childbirth experience: A systematic review. International journal of nursing practice, 25(4), e12722. https://doi.org/10.1111/ijn.12722

Neczypor, J., & Holley, S. (2017). Providing evidence-based care during the golden hour. Nursing for Women’s Health, 21(6), 462-472. doi: 10.1016/j.nwh.2017.10.011

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