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A Typical Pregnancy Journey – Visits, Investigations, Classes, Immunisations and Ultrasounds and, um, having a baby…

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When I ask my new patients if they have any questions for me, the most common one is this:

“How much is this going to cost me?” (just kidding, my fees are on my website)

…closely followed by:

“What’s the process from here?”

I’ve tried to figure out the best way of describing the pregnancy journey (a video involving sock puppets?) but settled on what I do best – writing about it. It is really important that you understand that what follows is simply a description of the processes we need to go through to get you from your first visit with me until after you go home with your baby (or babies!).

So, in this document I am deliberately ignoring the social, physical and emotional stuff that goes with pregnancy and having a baby even though I know how important they are. These are the jobs we need to get done in my office.

I am also describing a typical, straightforward pregnancy and of course you could argue there is no such thing. It is really important that you understand that we adapt and alter this approach entirely according to your needs and wishes and, as a former PM of The UK (Harold Macmillan) once said: “Event’s, dear boy, events.”

It is important that you understand that what is described here is the way I provide pregnancy care – I can’t speak for what other providers do. At every visit you have with me I will, at a minimum, check your blood pressure and perform an ultrasound scan of your baby.

It’s a bit old fashioned but you might want to literally tick all of the things below as we go along.

So, you’re knocked up! – getting started

You have missed your period and you’ve just had a positive pregnancy test. Congratulations.

A word about weeks – as far as we are concerned your pregnancy begins on the first day of your last period (LMP) so, strictly speaking you are two weeks pregnant when you fall (I love that description) pregnant. WTF? Anyway, your due date is exactly forty weeks from the first day of your LMP and – pay attention – when you are half way through, say, your seventh week you are six and a half weeks pregnant (as I am in my 59th year I’m still 58 – OK?).

WEEKS FOUR TO EIGHT:

  • Get along to your GP to:
    • Confirm your pregnancy, 
    • Organise your blood tests (but I will do these if your GP doesn’t),
    • Organise a dating ultrasound if needed (if you are seeing me at around 8 weeks, I can do this for you),
    • Give you a flu shot if appropriate (and it usually is),
    • Have a chat about foods to avoid and other aspects of normal pregnancy,
    • Start a pregnancy multivitamin – but you should already be on this, and
    • Discuss your care for the pregnancy and birth – public v private, Drs v midwives etc – and write the relevant referral

 

WEEKS EIGHT TO 14:

  • Have your first visit – including an ultrasound scan (so come with a full bladder) – with me (if it’s me)
  • At that visit I will:
    • Take a full medical history, 
    • Examine you (usually take your blood pressure, listen to your heart, check your breasts for lumps and perform a PAP smear if you are overdue for this),
    • Perform an ultrasound scan of your baby, 
    • Organise any outstanding blood tests, 
    • Talk about where to give birth,
    • Manage your nausea and vomiting if needed,
    • Organise testing for your Carrier Status for various conditions (please see my information sheet Prepregnancy Genetic Carrier Screening),
    • Talk about prenatal testing for Down Syndrome and other congenital abnormalities – and organise these tests. These tests and scans will be performed at a dedicated women’s health ultrasound practice.

All of your prenatal testing is discussed in my information sheet on First Trimester Testing. Most women these days have the Harmony / NIPT / NEST test performed at 10 weeks gestation and what we call the Early Morphology Scan at 13 weeks.

I will then see you at around 14 weeks to:

  • Discuss all of your results with you and, if needed, organise further testing
  • Organise your booking into the hospital where you will give birth, and
  • Give you your referral for your 19-week morphology scan. This too is performed with an expert outside ultrasound practice (see my information sheet on the 19-week Morphology scan).

WEEKS 16 / 17:

We will meet up mainly to check on your baby (especially as most women are not feeling any baby movements at that stage and their early pregnancy symptoms may have receded so they like to check in on the baby).

In my practice around now you should be having your booking visit with the midwife in my rooms. She will assess things like your mental health and discuss a number of lifestyle matters relating to pregnancy. She will make any referrals for you that she finds appropriate (e.g. physiotherapist, dietician or psychologist).  

 

WEEK 20:

We will meet up to go through the results of your 19-week morphology scan and – again – organise any further testing, referrals or follow up that may be needed as a result of that scan.

By this time the hospital should have confirmed that you are booked in with them and they will have asked you to enrol in their labour and birthing education classes. Please do.

If we know that you are having a planned caesarean (for whatever reason) we will book the date of your Caesar with the hospital.

It is now time for you to organise for you and – if needed – your family to have your / their Whooping Cough vaccination (Boostrix) at around 24 weeks gestation. Women should have this vaccination every time they are pregnant as the antibodies generated by each shot cross the placenta and protect the baby from birth).

 

WEEK 24:

We will meet up and I will check your blood pressure and your baby’s growth (usually its tummy size) and welfare (mainly amniotic fluid volume and blood flow through the umbilical cord). We will start asking you to provide a urine sample at each visit from here on – mainly to check for protein in your urine, which can be an early warning sign of high blood pressure in pregnancy.

We will also organise your next bunch of blood tests. This includes a two-hour Glucose Tolerance Test (GTT) to check for Gestational Diabetes and checking your iron levels (amongst other things). These tests should be performed at around 26 to 28 weeks gestation. Please see my information sheet on Testing for Gestational Diabetes. 

 

WEEK 28:

This is time for another visit with me and another check of both you and your baby. We will discuss the results of your recent blood tests and organise any actions arising from them (such as iron treatment).

If your blood group is Rh Negative (you will know this by now) we will give you your first routine Anti D injection.

You should have had your Whooping Cough vaccination (and flu shot if appropriate) by now.

28 weeks is about when you should begin to pay more close attention to your baby’s movements. Please see my information sheet Your Baby’s Movements.

28 weeks, or thereabouts, is another good time for a visit with the midwife in my office – we don’t charge for these, by the way – just to check in on how everything is going and, again, make any allied health referrals needed.

 

WEEKS 30 and 32:

You will come and see me for routine (but careful) checks of both you and your baby.

You should be doing your birthing classes around this time and – again – your Whooping Cough vaccine should have been done.

 

WEEK 34:

This is another routine visit. If you are blood group Rh negative, I will give you your second Anti D shot.

A couple of optional things can take place at around 34 weeks:

  • Because I always perform an ultrasound scan at every antenatal visit, I don’t routinely organise a third trimester formal ultrasound with an external provider for everyone. If I (or you) have any concerns about your baby’s growth we may do a formal ultrasound around now. We will also request one if you have any risk factors for a baby that is either too big or too small. 
  • We may repeat your blood tests around now or we may not. This usually depends upon whether you have any medical issues (e.g. an underactive thyroid) or whether there were any issues identified at your 26-week blood tests, such as a low iron level.

 

 

WEEK 36:

This is another routine visit. However:

This is when we perform your low vaginal swab test for Group B Strep. This is discussed in my information sheet on Group B Strep.

We usually discuss the impending birth in an ongoing fashion rather than at any one specific visit but certainly 36 weeks is a good time to discuss matters like your wishes and expectations for the birth, pain relief and any other issues on your minds.

Around 36 weeks is another good time to have a meeting with the midwife to talk about – mainly – birth and breastfeeding.

And a word about Birth Plans:

Most obstetricians – even if they don’t admit it to you – have, at best, mixed feelings about formal birth plans. As Mike Tyson says: “Plans are pretty good until someone gets punched in the face.” I encourage you to express your expectations and wishes clearly and if writing them down helps then that is completely fine. However, in doing so I ask you to remember:

  • To be flexible – events (“Dear boy”) can overcome or even overwhelm everyone’s wishes on the day, 
  • Remember the people caring for you have nothing but the best of intentions and have seen all of this a few times before, and
  • There are a number of things – such as emergency caesareans or forceps births or episiotomies – that you will no doubt not want to experience but please remember we don’t want to do those things either unless they are necessary.

 

WEEKS 37, 38 and 39:

We switch to weekly visits from 36 weeks gestation. The reason for the increased frequency of the visits are to keep a close eye on your blood pressure and the growth and welfare of your baby.

Of course, it is entirely possible that you may give birth during this time.

Engagement is a term I rarely use (in obstetrics, at least). Strictly speaking your baby’s head is engaged when its widest part has entered the upper part of your bony pelvis. This can be a very subjective assessment (and your baby’s head could be engaged when you are upright but not when you are lying down) and I think it a very poor predictor of when you might labour and how your labour might progress (plus an engaged head can become unengaged later on). And “engagement” is outside our circle of control so I’m not fond of obsessing about it. I have seen plenty of women with unengaged heads at 39 weeks have perfectly normal births and I have seen plenty of women with engaged heads at 36 weeks go overdue and need a caesar.

I am more interested in position – occipito anterior (OA) versus occipito posterior (OP or simply “Posterior”). Babies fit out best if their spines are towards the front of your abdomen (anterior) than if their spines are against your spine (posterior). While some anterior babies go bad in labour and turn posterior (grrr!) labour is – in the main – more straightforward with an anterior than with a posterior baby, especially if that posterior baby doesn’t turn to the anterior position in late labour. If your baby is posterior when you are fully dilated unfortunately you have a significantly higher risk of a Caesar or an instrumental birth than if it is anterior. But – like engagement – your baby’s position is generally outside our circle of control.

(Actually, I think a sock puppet video might be best for explaining anterior versus posterior positions).

Now, all of the above said, if it is your first baby and you are past your due date and your baby’s head is in the posterior position and it is not engaged and your cervix is closed and we think it is a biggish baby and we are having to think  about inducing your labour you may choose to have an elective Caesar on the grounds that achieving a perfectly natural birth is fairly unlikely in those circumstances (just “difficult, but not impossible” as they say in The Godfather). Obviously, we will discuss this situation in detail should it arise.

 

WEEK 40:

If this is your first pregnancy there is a good chance you’re still pregnant on your due date. If we have not done so already this will be when we discuss what we might do if you go overdue (and that is a whole information sheet in itself). This is often an appropriate time to perform a gentle internal examination to see how “ready” your cervix is for labour and birth.

A few words about internal examinations and “stretches and sweeps” (another term I rarely use). Lots of practitioners perform relatively frequent internal examinations in the final weeks of pregnancy. The purpose of this eludes me. A “stretch and sweep” is an examination designed to attempt to bring on labour by stretching open the cervix with the examiner’s fingers and literally separating the fetal membranes from the wall of the cervix and lower uterus. The first problem with doing this is that it blinking well hurts and can cause some concerning bleeding afterwards. The second problem is that while doing this does reduce the need for induction of labour in post-dates pregnancy (only) it does not alter any other labour outcome such as the need for caesarean childbirth. Thirdly – and obviously – if the cervix is closed – and it usually is in first timers before their due dates – it’s impossible to do a “stretch and sweep.”

 

AFTER THE BIRTH:

We always organise a visit with the midwife in my office around a week after you go home with your baby (or babies). At this visit she will make sure breastfeeding is going well, perform any checks needed (e.g. your blood pressure), remove any stitches that need removing (although most are dissolvable) and – again – organise any referrals you may need, such as to a lactation consultant. An important part of this visit is checking your mental health status in case you have any early signs of Postnatal Depression (PND). 

I will see you for your six-week postnatal check; although I am always available to deal with any problems, complications or concerns that may have arisen for you during or after the birth.

Your six-week check is where we say goodbye…until next time.

 

Cheers

– Rob

February 2020

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