Prenatal and postpartum care
Return prenatal visits
The return prenatal visits follow a regular schedule:
- Every 4 weeks through 28 weeks’ gestation
- Every 2 weeks through 35 weeks’ gestation
- Every 1 week until delivery
In follow-up prenatal visits, the medical assistant should collect a urine specimen for urinalysis, weigh the patient, measure her blood pressure, and answer questions about diet and health habits. The mother should gain approximately 10 to 12 pounds in the first half of pregnancy and another 15 to 17 pounds during the second half. Experts believe that a healthy weight gain is somewhere between 25 and 35 pounds.
Fetal heart tones
A Doppler monitor may be used to hear the baby’s heart tones somewhere between 9- and 12-weeks’ gestation. Once recorded, the fetal heart rate is assessed at each subsequent visit. It is important to remember that a fetal heart rate should be between 120 and 160 beats per minute. If you get a reading of between 60 and 100 beats per minute, you may be assessing the patient’s heart rate and not the fetal heart rate.
Fundal height measurement
Fundal height measurement is routinely done during the return prenatal visit. As the uterus grows during pregnancy, it will rise into the abdominal cavity. Between weeks 8 and 13, the fundus (the top of the uterus) can be palpated above the symphysis pubis. The fundal height measurement is taken with a flexible tape measure, measuring from the symphysis pubis to the fundus of the uterus. The height is measured in centimeters (cm) and most often matches the number of weeks the patient has been pregnant. For example, if the patient is 25 weeks pregnant, the provider would expect to see a fundal height measurement of 25 cm. This is only considered accurate for the first and second trimesters. If the fundal height measurement does not match the number of weeks pregnant, this could signal an issue with the pregnancy. Fundal height measurements that are either larger or smaller than expected could indicate the following:
- Slow fetal growth (intrauterine growth restriction)
- A significantly larger than average baby (fetal macrosomia)
- Too little amniotic fluid (oligohydramnios)
- Too much amniotic fluid (polyhydramnios)
If the provider suspects an issue, an ultrasound would likely be ordered to determine what was causing the unusual measurements.
Postpartum visit
The patient should return about 6 weeks after delivery for a postpartum visit. At this visit, the provider will do a pelvic examination to make sure everything is healing. If a cesarean section was done, the incision site would also be checked for healing. If the patient is interested in using contraceptives, the provider will talk about contraceptive choices. If the patient previously used a diaphragm, the fit will need to be checked. There may also be a discussion about how breastfeeding is going. Any of the patient’s questions about care for the baby should be answered at this visit.
The postpartum visit is also an opportunity to see how the patient is doing emotionally. The provider will ask questions about the patient’s moods and check for signs of postpartum depression.
Postpartum depression
- The incidence of postpartum depression (PPD) is not clear, but an estimated 10% to 20% of women struggle with major depression before, during, and after delivery of a baby. Fewer than half of these are diagnosed in routine office visits.
- Postpartum depression can be diagnosed a month to a year after childbirth. Women with a history of depression during pregnancy should be monitored for signs of postpartum depression for a minimum of 4 months.
- Risk factors include a history of depression, abuse, or mental illness; smoking or alcohol use; anxiety during pregnancy and fears over childcare; lack of financial resources and secure relationships; a fussy or colicky infant; and lack of social support.
- Symptoms of postpartum depression include anorexia and insomnia; irritability and anger; overwhelming fatigue; loss of interest in sex and lack of a feeling of joy in life; feelings of shame, guilt, or inadequacy; severe mood swings; difficulty bonding with the baby; withdrawal from family and friends; and thoughts of harming oneself or the baby.
- Postpartum depression must be detected as soon as possible so that treatment can begin; untreated postpartum depression may last for a year or longer. Treatment includes both counseling and antidepressant medication.
The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for perinatal depression (between the 28th week of pregnancy and the 28th day after birth). Healthcare professionals working with the perinatal population should use the EPDS as a routine part of postnatal care because the EPDS is a valid and reliable means of detecting PPD. This screening tool is user-friendly, easy to administer, and easy to score. A score of 9 to 13 is considered the cutoff for PPD; the mother should be referred for further evaluation or treatment. Users may reproduce the scale without further permission, providing they respect the copyright by quoting the names of the authors and the title and the source of the paper in all reproduced copies. The EPDS can be accessed at the American Academy of Pediatrics website: Edinburgh Postnatal Depression Scale (EPDS).
Medical assistants should set up for this visit just as they would for a pelvic examination. You should also be aware of the patient’s mood and body language. These can alert you to potential issues with postpartum depression. You should also have a list of provider-approved resources for the patient regarding postpartum depression or breastfeeding issues.
Assisting with diagnostic procedures
Throughout the pregnancy, there are special tests and procedures that may be done to assess the status of the pregnancy. In the next section, we will explore some of the more common tests and procedures.
Ultrasound
Ultrasound exams are typically done once during the first trimester and then again between weeks 18 and 20 to assess fetal development and thereby confirm the age of the fetus and proper growth. The sex of the baby can also be determined at that time. It is best if the patient has a full bladder for the ultrasound. The full bladder provides a great “window” for the sound waves to travel through, allowing for the best possible images. The patient should be instructed to drink two or three 8-ounce glasses of water 1 hour before the scheduled ultrasound.
Laboratory testing
Between weeks 15 and 18 of pregnancy, the provider may suggest that the patient have a maternal blood screen in order to detect any risk of fetal and chromosomal disorders. This could be a triple screen test (also known as AFP Plus and multiple marker screening) or a quad screen test. Both tests screen for the following:
- Alpha-fetoprotein (AFP)
- Human chorionic gonadotropin (hCG)
- Estriol
The quad screen also tests for inhibin-A. These tests are used to evaluate if there is an increased chance of certain chromosomal conditions, such as Down syndrome. The alpha-fetoprotein evaluates the chances of neural tube defects, such as spina bifida.
If the patient is at risk for gestational diabetes, the provider will likely order a glucose challenge test. Risk factors for gestational diabetes include the following:
- A body mass index (BMI) before pregnancy of 30 or higher
- A mother, father, sibling, or child with diabetes
For a glucose challenge test, the patient must drink a glucose solution. One hour later, a blood test will be done to measure the glucose level. A blood glucose level of 130 to 140 milligrams per deciliter (mg/dL) is considered normal. If the result is higher than that, a glucose tolerance test may be ordered. The glucose tolerance test involves having the patient fast overnight before coming in for a blood glucose reading. The patient will then drink another glucose solution and have her blood glucose level checked every hour for the next 3 hours. If two out of the three readings are higher than normal, the patient would be diagnosed with gestational diabetes.
Group B streptococcus is a common bacterium found in the intestines. It is usually harmless in adults, but in newborns it can cause group B strep disease. This is a serious illness for newborns. A group B streptococcus culture of the lower vagina can be performed between weeks 32 and 36. If the result is positive, the mother is treated with intravenous (IV) antibiotics to prevent fetal exposure during vaginal birth.
Amniocentesis
Amniocentesis involves needle aspiration of approximately 2 tablespoons of amniotic fluid after week 14 of pregnancy. The aim is to detect genetic and chromosomal abnormalities or inherited metabolic disorders. Potential complications include the following:
- Miscarriage
- Fetal injury
- Infection
- Premature labor
- Maternal hemorrhage
Results take up to 2 weeks.
Chorionic villus sampling
Chorionic villi are tiny placental projections, the cells of which have the same genetic material found in fetal cells. Chorionic villus sampling (CVS) involves the removal of a small piece of the chorionic villi, either transvaginally or through a small incision in the abdomen. Cellular screening at 8- to 12-week gestation provides early detection of genetic or chromosomal disorders. Potential complications include the following:
- Accidental abortion
- Infection, bleeding
- Fetal limb deformities
Results are available within several days.