What Happens At My 36 Week Visit?



Can I share a truth with you guys? One of my favorite things about these templates is that you can share them far and wide. I have had the privilege of taking care of so many women but have also moved a lot – so our relationships seem temporary. Luckily, I stay in touch with so many of these mamas. And you can bet I shared some templates with them!

This template has a few new formatting details. First, there is a bishop score for providers to educate and counsel on the aspects of the cervix. I added this as a helpful lead in to cervical ripening or induction.

Second, the back of the template has a focused resource section for the education pertinent to 36 weeks.

Let me know what you think of the format and the template!

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 36 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 36 week visit:

  • Have you packed your hospital bag?
  • Do you have any questions about what to pack in your bag?
  • Do you know where to go in the middle of the night if your water breaks?
  • What is your plan for pain management in labor?
  • What breastfeeding education have you completed?
  • Are you interested in learning about perineal massage?

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 36 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 36 week mamas, you can at least palpate where the baby’s head is! You can read all about the maneuvers here (Superville & Siccardi, 2021).
Laboratory testing

The one lab that is universally done at the 36 week visit is the group beta strep screen.

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).

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 36 week visit has a lot of components that set the foundation for the last few prenatal visits. These are the topics I like to review, but the sky is the limit!


Cervical exams

Let’s start with what a cervical exam is. A cervical exam is an exam of the posterior vagina in order to palpate the cervix with the provider’s fingers to check the dilation and effacement of the cervix, while also checking the baby’s station in the pelvis.

Two years ago I did a whole post on “What’s a cervical exam?”. The post has some great pictures and videos and is definitely worth the read for all of the basics.

Why are some women offered cervical exams every week starting at 36 weeks of pregnancy until they birth their babies? Can’t it help you know when you are going to go into labor? No, it usually doesn’t help you know when you are going to go into labor. Labor is defined as contractions are causing cervical change. So, if you are 4 centimeters dilated but you are not having contractions, it is anyone’s guess as to when you will go into labor.

Unnecessary cervical exams can increase the risk of infection during labor. Infection during labor is called IAI or intra-amniotic infection. IAI used to be called chorio, short for chorioamnionitis. Gomez et al. (2021) found that women with more than 8 cervical exams in labor had a 1.7 times higher risk of an infection during labor than women with only 1-3 cervical exams in labor. In the retrospective study of 20,000 women, some risk factors were associated with a higher risk of infection: prolonged rupture time, nulliparity (first time pregnancy), Black race, Medicaid insurance, higher gestational age, and higher body mass index. Interesting, smoking and group beta strep positive women were not at increased risk for infection.

Evidence Based Birth also offers a great video recapping other evidence on cervical exams during prenatal visits:



the bishop score

The Bishop scores was developed in 1964 by Edward Bishop (Wormer, Bauer & Williford, 2021). The score exams the position of your cervix, the soft to firm nature of your cervix (cervix consistency), the thin to thickness of your cervix (effacement), how open or closed your cervix is (dilation) and the position of the baby’s head in the pelvis (station). The scoring system is from 0 to 13 points.

Traditionally, a score of 6 indicates a cervix that is ready for labor, while a score that is less than 6 may not be ready for labor (or, this cervix may need more ripening during an induction).

The Bishop Score has a sensitivity of 75% and a positive predictive value of 83% (these mean it’s an appropriate scoring system to consider), but it has a poor specificity and negative predictive value (Wormer, Bauer & Williford, 2021).

Regardless of a cervix’s score, it is important to discuss all of the elements of a cervical exam and if a score should be part of a discussion about induction, labor, or postdates management.


labor pain managemenT
Source

Regarding pain management, there are two paths to manage labor and birth pain:

  • Non-pharmacologic methods
  • Pharmacologic methods

Your place of birth (home, hospital, birth center…) may only have some of these options. Do your research and ask what is and is not offered at your planned place of birth. ACOG supports that combinations of non-pharmacologic and pharmacologic methods are appropriate for women in with labor discomfort or pain (ACOG, 2019).

Non-pharmacologic methods are wide and varied. Some methods can be combined. Some methods are therapeutic for some women and disliked by others. Regardless, almost all women have pain or discomfort in some part of labor. Take a look at these and decide which methods are best for you!

  • Labor support from partner, doula, friend, birth team
  • Deep breathing
  • Music
    • Music has been shown to reduce pain levels in active labor and during the first hour postpartum when compared to women that did not listen to music during labor (n=30) (Buglione et al., 2020).
  • Calming environment (lights dimmed, TV off…)
  • Frequent position changes
    • Upright positions increase maternal comfort, promote good position of the baby’s head in the pelvis, and are associated with a shorter first stage of labor by 1 hour, 22 minutes!
    • Upright positions are also associated with a 29% reduction in cesarean birth!
  • Rocking or swaying while in a standing position
  • Use of a birthing ball
  • Massage or counter pressure
  • Hypnotherapy
  • Yoga or stretching
  • Hot bath or shower
  • Hot packs or cold packs
    • Heat therapy used with a birthing has been shown to be an effective intervention for labor pain and sacral pain (Taavoni et al, 2015).
  • Aromatherapy (on skin or via diffuser)
    • Aromatherapy has been shown to be helpful in latent labor, not in active labor (Tanvisut at al, 2018).
  • Use of TENS unit
  • Sterile water injections (especially therapeutic for back pain during labor) (ACOG, 2019; BirthTOOLS, 2022; National Institute of Health [NIH], 2017)

Pharmacologic methods are less varied but differ in how the method is administered.

  • IV (intravenous) medications – often times this is morphine derivative (Stadol, Fentanyl, Demerol…)
  • Nitrous oxide
  • Epidural

Here are some other educational sources coping with labor pain:

Interested in a video option? Check out the “Three R’s of Labor” by Peggy Simkin


induction of labor

What is induction of labor? Induction is when a woman is given medications or interventions to start labor before labor starts by itself. Inductions are either recommended by a medical professional for certain pregnancy conditions or done for elective or social reasons. Discussions about inductions should include shared decision-making with an emphasis on the alternatives, benefits and risks to each pathway.

Read more on induction at these resources. Discuss any questions or concerns about induction that you may have at your upcoming visits.


Perineal massage

Perineal massage is exactly what is sounds like. The vagina is gently massaged in the last month of pregnancy to help the tissue stretch and to help prevent or limit tearing of the vagina during birth.

Perineal massage isn’t for everyone, but it is easy to perform at home by the woman or her partner.

Studies found that perineal massage reduced tearing by about 10-20%, reduced episiotomies by 20%, reduced postpartum pain and improved healing (Abdelhakim et al., 2020; Beckmann & Stock, 2013). Learn how to perform perineal massage here: How to Do Perineal Massage (ACNM).


pack your hospital bag

There are a number of lists available on the internet. These are the things I mention on the regular to mamas in the clinic that ask “What should I pack in my hospital bag?”

  • Your heating pad (electric or rice soak is okay)
  • Chapstick
  • A comfy couch blanket
  • Your preferred pillow for sleeping (hospital pillows are terrible)
  • A book to read
  • Whatever outfit you want to labor in (no, you don’t have to wear the hospital gown)
  • Comfy sweats or PJs for after the baby is born

Most hospitals provide (and these are included in your hospital bill): infant diapers, wipes and a onesie or shirt; postpartum underwear, dermoplast, tucks pads and postpartum pads for the mama; pain medication; hospital socks; hospital gowns; lanolin nipple cream or similar; boppy pillow or pillows for nursing; towels.

Other items you could pack include:

  • Toiletries (ponytail holders, deodorant, travel size shampoo/conditioner, mouthwash)
  • Slippers
  • 1-2 infant onesies
  • Infant pacifiers
  • Phone charger
  • Nursing bra or nursing top
  • A preferred nipple balm
  • Bathrobe
  • Snacks
  • Aromatherapy, diffuser, TENS unit, LED candle lights
  • Car seat

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 36 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 36 weeks? Send me an email with your thoughts or recommendations!

As a pregnant mama, what topics do you want covered at this point in pregnancy? And…the 36 week template is LIVE! Check it out here.

Let me know!

Jamie



1 year ago on the blog…The State of Midwifery (2021)

2 years ago on the blog…The Future of Midwifery (Part 3 of the State of Midwifery)


Links in the post

ACOG’s FAQs: Labor Induction

ACOG’s FAQs: Medications for Pain Relief During Labor and Delivery

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

ACNM handout: Coping with Labor Pain

ACNM handout: Epidural Analgesia for Labor Pain

ACNM handout: How to Do Perineal Massage

ACNM handout: Induction of Labor

ACNM handout: Using Medication to Cope with Pain

ACNM handout: Using Water for Labor and Birth (ACNM)

ACNM Position Statement on Induction

American Family Physicians: Managing Pain in Labor (2021)

BirthTOOLS: Coping with Labor

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

Video: “Three R’s of Labor” by Peggy Simkin


References

Abdelhakim, A. M., Eldesouky, E., Elmagd, I. A., Mohammed, A., Farag, E. A., Mohammed, A. E., Hamam, K. M., Hussein, A. S., Ali, A. S., Keshta, N., Hamza, M., Samy, A., & Abdel-Latif, A. A. (2020). Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials. International urogynecology journal31(9), 1735–1745. https://doi.org/10.1007/s00192-020-04302-8

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. (2019). Approaches to limit intervention during labor and birth. Committee Opinion, Number 766. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth

Beckmann, M. M., & Stock, O. M. (2013). Antenatal perineal massage for reducing perineal trauma. The Cochrane database of systematic reviews, (4), CD005123. https://doi.org/10.1002/14651858.CD005123.pub3

BirthTOOLs. (2022). Coping with labor. https://birthtools.org/MOC-Coping-with-Labor

Buglione, A., Saccone, G., Mas, M., Raffone, A., Di Meglio, L., di Meglio, L., Toscano, P., Travaglino, A., Zapparella, R., Duval, M., Zullo, F., & Locci, M. (2020). Effect of music on labor and delivery in nulliparous singleton pregnancies: a randomized clinical trial. Archives of gynecology and obstetrics301(3), 693–698. https://doi.org/10.1007/s00404-020-05475-9

Centers for Disease and Control and Prevention. (2020). Group b strep. https://www.cdc.gov/groupbstrep/about/fast-facts.html#:~:text=About%201%20in%204%20pregnant,onset%20GBS%20disease%20in%20newborns

Gomez Slagle, H. B., Hoffman, M. K., Fonge, Y. N., Caplan, R., & Sciscione, A. C. (2022). Incremental risk of clinical chorioamnionitis associated with cervical examination. American journal of obstetrics & gynecology MFM4(1), 100524. https://doi.org/10.1016/j.ajogmf.2021.100524

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

National Institute of Health. (2017). What are the options for pain relief during labor and delivery? https://www.nichd.nih.gov/health/topics/labor-delivery/topicinfo/pain-relief

Taavoni, S., Sheikhan, F., Abdolahian, S., & Ghavi, F. (2016). Birth ball or heat therapy? A randomized controlled trial to compare the effectiveness of birth ball usage with sacrum-perineal heat therapy in labor pain management. Complementary therapies in clinical practice24, 99–102. https://doi.org/10.1016/j.ctcp.2016.04.001

Tanvisut, R., Traisrisilp, K., & Tongsong, T. (2018). Efficacy of aromatherapy for reducing pain during labor: a randomized controlled trial. Archives of gynecology and obstetrics297(5), 1145–1150. https://doi.org/10.1007/s00404-018-4700-1

Wormer, K. C., Bauer, A., & Williford, A. E. (2021). Bishop Score. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470368/

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