What to Expect at Your First Prenatal Visit

The First Prenatal Visit Sets the Foundation for Personalized Pregnancy Care

Dr. Jones: You are pregnant with all the joy and worry and ambivalence that comes with a pregnancy. It's time to schedule your obstetrical care, your first prenatal visit. I'm Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is the first prenatal visit at the "7 Domains of Women's Health."

The first visit sets the foundation for personalizing your obstetrical care based on your personal history, your family history, your obstetrical history, and your current health.

And to help us think about this, we have Abby Rizk in the virtual Scope studio. Abby is a certified nurse-midwife at the University of Utah Health who provides comprehensive prenatal and gynecologic care. She's the Clinical Practice director of Birthcare Health Care and the Division Chief of the Division of Midwifery.

So that first prenatal visit, as I say, it's the foundation, but tell me why it's such an important step in pregnancy care.

Abby: It helps to set the tone for the expectations in pregnancy, and really helps to outline what people can expect during their pregnancy and with their care from us at the University of Utah and the midwifery practice. We go over a lot. We go over history, we go over questions that people might have, and then we review what to expect in the coming months.

Dr. Jones: Well, can you take me through it from start to finish?

Abby: Yeah.

Dr. Jones: So they walk in, and they've got all their clothes on, and they're nervous, or this is their fifth baby, and they're not nervous. So tell me what happens.

Abby: When people walk in, I like to, and I think most of us do, help people feel less nervous. So we try to have just more of a conversation.

I always start the visit out just asking people how they're feeling. And we also like to ask how they're feeling about being pregnant. So we want to make sure that this is something that they are happy to move forward with.

Once that is established, then I like to jump into, "Well, just tell me what questions you have off the top of your head," because a lot of people will come in with a set of questions that they want to kind of say, "Bam, bam, bam." And so we'll talk about some of their questions.

And then I outline the visit. I like to say, "First, what we're going to do is just talk about you, how you're feeling, any questions you have. I'm going to talk to you about our practice and what to expect with your prenatal care here with us, the midwives, and at The U, and what to expect on labor and delivery and how that works with the midwives and our backup positions."

We go through what labs they should expect to get during their pregnancy, what ultrasounds they should expect to get during their pregnancy. And also, we talk about genetic testing.

And then we go through their history and make sure they're appropriate for midwifery care, highlighting any issues that we might need to follow up on that are possibly more higher risk. And then we always do a quick bedside ultrasound to do a crown-rump length and ensure that somebody's dating is correct.

Actually, if I could go back, what I first do is review their dating from their last menstrual period, or if they had any scans yet that have already dated their pregnancy. We want to make sure we have our dating correct as early as possible.

Early Pregnancy Ultrasounds Help Confirm Dating and Viability

Dr. Jones: Well, that's something that's relatively new, the concept of what we used to call dating ultrasounds or viability scans. And it's really something that people want. They're coming in, they don't . . . Maybe they barely even feel pregnant. Maybe their boobs are kind of tender, but they can't feel a baby there. And there's nothing more reassuring to know that they have a heartbeat and that their dates are whatever they think they are. Or if they don't have a heartbeat, then they don't have to wait another month or two before a spontaneous abortion.

So I think that the relatively routine scan in your practice is really what patients are hoping for. They're not really keen on the blood tests, and they're not keen on the other stuff, but they would like to confirm that this is at least starting off as a healthy pregnancy. I'm so glad you guys do that.

Routine Prenatal Lab Work Protects Both Parent and Baby

Well, some of the tests, the list . . . We call it the Prenatal A Package. I don't know what you guys call it, but it's got a whole lot of blood tests. Can you tell me? We usually just say, "You're going to go get your screening blood work," but it's 10 things. Can you talk about that? And do you tell them all those 10 things, or you just say, "You're going to get your screening blood work," and leave it at that?

Abby: I actually list just a few, and then I show the list on the computer so they can read it. But it's blood type and screen, making sure there are no antibodies in their blood. We check for some STIs like HIV, Hep B, Hep C. We always want to check a blood count and an iron level to check for anemia and possibly iron deficiency. And we also do syphilis. We check an RPR. And then we do a urine test to also check for an asymptomatic urinary tract infection, and we always check for gonorrhea and chlamydia.

Dr. Jones: Well, I know a lot of women in my fertility practice said, "You don't need to screen me for all those things." And the answer is for many patients, they are at very low risk. But all these sexually transmitted infections that you talked about, including syphilis, HIV, and hepatitis B, those are transmitted to the baby, and you really want to protect your baby.

You say, "Yeah, I know you don't think you're at risk, and here's why. It doesn't cost all that much to do it. And in fact, your insurance covers it. And in fact, because it goes to the baby, you want to know that earlier than later."

I mean, how do you have that conversation?

Abby: Yeah, people don't usually push back against it, but if they do, that's what we say. We say, "Sometimes if you were exposed at a previous point in life, these can lay dormant for a while, where you might not have symptoms of some of these infections, and they can affect your pregnancy and the fetus." And so if people are concerned with getting those tests, they're usually on board to do it.

Early Prenatal Visits Open the Door to Genetic Testing Options

Dr. Jones: So, Abby, a lot of people want to know . . . I mean, if they're only eight weeks, they can't see on ultrasound what the sex, not gender, of their fetus is. But they may also be worried about some relatively common genetic diseases. So what about genetic testing? Do you talk to them about that?

Abby: We do. We spend some time on genetic testing, and we go through the options because there are several options you can take. If you want all the genetic testing, including the diagnostic test of chorionic villus sample, which is done before 15 weeks of pregnancy, or amniocentesis . . .

Dr. Jones: That's where they take a little bit of the placental tissue and test the fetus itself.

Abby: Ultrasound-guided. And we used to say there was a 5% risk of miscarriage with that. That data is based on the test being done in the '60s with the ultrasound technology we had then. So we actually think the risk is much lower now of having a miscarriage when you get these tests done. But those are the only diagnostic tests that can tell you exactly what the chromosomal makeup is of the fetus.

The other main test is a screening test, but it's pretty accurate. It's a trisomy test looking at Trisomy 21, otherwise known as Down syndrome, Trisomy 13, Trisomy 18, and some other sex-linked trisomies. And that is the test that people can do after 10 weeks' gestation that tells them also the fetal sex.

It's really important, though, before we order that test and do that test, that we know it's a singleton pregnancy or not a singleton pregnancy because that can affect . . . So we like to do that ultrasound first at the visit before ordering that test.

And then if people want further genetic testing, like carrier testing, to see if they're a carrier for anything and if their partner needs to be tested, we would refer them to the genetics perinatal counselors who would meet with them virtually and decide what testing they want to do.

Dr. Jones: Right. So this is another reason why it's important to get your first prenatal visit relatively early, because you might have something that runs in your family that you're worried about, and you want to make decisions early or have information early.

There's so much more that's available now for people who have genetic risks or people who are just worried about relatively common things, cystic fibrosis or some other things.

So I think getting in early enough that you can get the maximum . . . You may not want it all, and you don't have to have it all, but to get the maximum amount of information that's important for you and your family, that can be done, and it's important to start early.

Abby: Yes, for sure.

Your Medical History Helps Personalize Your Pregnancy Care Plan

Dr. Jones: How do you make this prenatal care feel personalized? I said in the introduction that this is the foundation. If you don't know, as a provider, what your patient's family history, personal history, or obstetrical history is, you can't personalize their visit schedule and their care to them. So how do you help them understand that, "This is the way we make it just right for you"?

Abby: We talk about it in broad terms, as we just mentioned, all the lab work. And then when we go through their history, some things then are tailored based on their history, with any additional lab work that we might need to do.

We also are somewhat flexible in shared decision-making. So informed consent is a huge part of our practice, shared decision-making. And so if there is something that people are really feeling uncomfortable with that we are asking them to do, we will have a conversation about that and talk about risks and benefits of doing something or not doing something.

Dr. Jones: Yeah. And if a woman is going to get her first prenatal visit, how does she come prepared? What should she be expected to bring with her in terms of either information? How does she prepare herself or make the visit more useful to her and her future baby and to you?

Abby: It's really helpful if people come with a list of questions. Often, pregnancy brain is real, where there's some blood volume that doesn't get to your brain because you're shunting it to the uterus for growth. So coming with a list of questions.

Also coming with a really good history, health history, including family history. So we ask people to sometimes interview their family members ahead of coming in to the visit to make sure that we have a complete family history as well. And that's really it.

A Multidisciplinary Care Team Supports You Throughout Pregnancy

Dr. Jones: And then I think the unique thing about getting your care at what feels like a big and impersonal institution, but the fact that you do it through your practice . . . You have a big team. I mean, if someone's been struggling with depression and is on antidepressants, but they want to go off, you have psychological backup. You've got people who can help them. You've got social workers. You've got people who can help them with their benefits. Can you talk about your team and how big your team is?

Abby: Yeah, exactly. I feel really blessed to work at the University of Utah because we have so many excellent specialty services that are easy to access within the system.

We often connect people who might not be connected to behavioral health services if they're looking for talk therapy. If it is an issue of starting someone... because we will do a depression and anxiety screen as part of the new OB visit. And that's something that we feel comfortable prescribing.

But if they have a complex psychiatric history, they're taking medications that we're not as midwives comfortable prescribing, or they're on multiple psychiatric medications, then we can refer them to our psych experts, and they can manage that while we still continue to manage the pregnancy.

Thyroid, endocrinology, sometimes if people have some complex endocrinology issues, we might be working with endocrinology. Same with hematology. These are just some of the services that we often are working with outside of OB.

The most common one that we work with within OB is maternal-fetal medicine, who I refer to as our high-risk OBs, and they really are the experts in everything outside of normal in pregnancy. So we often are doing consults.

And what's nice at the University of Utah, which has been set up with several specialties, including maternal-fetal medicine, is we can do e-consults. So we'll always ask someone, "Do you want to see this specialist in person, or do you want me to send kind of a summary of what our question is?"

You might get a copay for that. They usually do because it's a consultative service. But it's really nice. It saves someone an extra visit, and then that information is part of their chart.

Every Pregnancy Deserves a Comprehensive First Prenatal Visit

Dr. Jones: Yeah. I think that in terms of making someone feel at home . . . You are going to be their medical home, but their medical home has many wonderful rooms they may never explore, but they might need some extra care as things evolve in the pregnancy. And that's why you can help them through all the kinds of steps in case there are problems that arise, or they've already arisen. I think that's really a foundational core of your practice, is that you're their home, but you can help them navigate.

Abby: Yeah. It's really a beautiful thing at The U, especially as midwives, because in a lot of places that might not have such strong connections to all these specialties, I think people might risk out of midwifery care.

But because at U of U Health, we have these collaborations, we tend to take care of . . . As far as midwifery care, we're kind of on the higher end of the high-risk spectrum. And then we partner a lot with MFM and do some co-management.

Dr. Jones: Well, Abby, I want to thank you for joining us so that we can talk to people about, in your practice, what a first prenatal visit is. I want to thank you for being here and talking to us.

And I want to just say the first prenatal visit of anyone's first pregnancy helps set the foundation for your individualized care. But the first prenatal visit of your second pregnancy is just as important. How your first pregnancy and delivery unfolded- easy-peasy, emergency cesarean, or high blood pressure at the end- it's important to know and plan the next one.

So don't go rogue wild on your pregnancy. You and your baby are too important. Be sure to start your prenatal care early in the first trimester so you can be in the hands of a team that knows you.