The First Prenatal Visit
The first prenatal visit is probably the most important one. In some cases, it will be with the referring primary care provider. In other cases, it will be the initial consultation with the OB.
The initial consultation will typically include:
Taking a history
This is the gathering of information on the course of the pregnancy thus far, prior pregnancies, medical problems and previous surgeries.
Performing a physical examination
If not previously done by the referring primary care provider, this will usually be a complete examination, including pelvic exam and Pap smear, if due.
Ordering lab tests and ultrasounds
Certain lab tests are routine for all pregnancies, and the OB will order them if they have not yet been done, along with any additional required ones.
A dating ultrasound (first ultrasound between 7 and 23 weeks) will be ordered, if not yet done. This scan will be used to establish the due date, as it has been found to be more accurate than the first day of the last menstrual period (LMP).
Discussion and Overview of Prenatal Care
Various topics will be reviewed. These include prenatal genetic screening, bleeding, nausea and vomiting and nutrition, self care, and immunizations.
The course of prenatal care will be outlined, and our call group arrangement will be explained. Hospital registration will be completed.
The planned mode of delivery will be identified.
A problem list will be formulated, and specialist referrals will be arranged, as appropriate.
Prenatal Genetic Screening and Testing
The goal of prenatal genetic screening is to identify pregnancies at higher risk for chromosomal abnormalities, in which case diagnostic testing can be offered for confirmation. The available options for prenatal genetic screening are complex and ever-changing. Perinatal Services BC provides a useful decision-making tool regarding the pros and cons of screening and the available options. The most recent update was published in April 2019.
Screening is very time-sensitive, with certain tests needing to be arranged at the end of the first trimester, and others in the second trimester. In cases where the first OB appointment is booked after the first trimester, these tests may need to be initiated by the referring provider.
MSP-funded options for screening depend on a woman’s age and other characteristics. What follows is a simple guide for women with spontaneously-conceived singleton pregnancies.
Women in special circumstances (multiples, IVF +/- ICSI, +/- PGT-A, personal or family history of chromosomal anomalies) will need to consult their OB for options that pertain to their specific circumstances. In complex situations, referral to Medical Genetics will be required.
SIPS (Serum INtegrated Prenatal screenING)
This is the MSP-funded option for women under 35 at delivery. It includes 2 sets of hormonal blood tests done in the first trimester (SIPS-1: 9w0d-13w6d; ideal 10w0d-11w6d) and the second trimester (SIPS-2: 14w0d-20w6d; ideal 15w0d-16w0d).
Results are reported 1-2 weeks after completion of SIPS-2.
If the risk of Down syndrome is greater than 1:900, NIPT is offered free of charge. If the risk is greater than 1:300, women can choose NIPT or amniocentesis.
IPS (Integrated prenatal screenING)
This test is available to women age 35 or older at delivery. It consists of the SIPS blood tests PLUS a specialized ultrasound done at 11w0d-13w6d (ideal 12w0d-13w3d) to measure the nuchal translucency (NT).
It is considered positive if the risk of Down syndrome is higher than 1:200, in which case further testing with either NIPT or amniocentesis is offered.
Quad Screen
This is essentially the SIPS-2 blood test and is the only MSP-funded option for women who have missed the window for SIPS-1 and/or the NT ultrasound.
If the risk of Down syndrome is greater than 1:900, NIPT is offered free of charge. If the risk is greater than 1:300, women can choose NIPT or amniocentesis.
NIPT (non-invasive prenatal testing)
NIPT is a blood test that screens for chromosomal abnormalities (trisomy 21, 18, 13, sex chromosome abnormalities) by measuring fetal DNA in the maternal circulation. It is generally more accurate than the hormonal-based SIPS and IPS.
It can be done as early as 9-10 weeks of pregnancy. The sex of the baby can be included in the report, upon request.
Currently, it is available on a private-pay basis at a cost of $495-650. Different ‘brands’ exist, with similar accuracy, but differences in methodology. The Panorama test is available through Lifelabs. Additional screening for rare disorders caused by chromosomal micro-deletions is available for about $250. The Harmony test is available through Dynacare nurse home collection, the hospital labs, and certain fertility clinics. Perinatal Services BC provides a useful summary.
Women with a positive SIPS/Quad (1:900 risk) or IPS (1:200 risk) are eligible for MSP-funded NIPT (Harmony only). The OB will complete a special form for this.
CVS and Amniocentesis
Women over 40 and women with a positive screening test (SIPS/Quad 1:300 risk or IPS 1:200 risk) are eligible for invasive prenatal testing. These tests are highly accurate but carry a risk of pregnancy loss.
Chorionic Villus Sampling (CVS) is done at 10.5-13 weeks, and it involves taking a sample of the tissue that will eventually form into the placenta. Results are available sooner than with amnio, but the risk of pregnancy loss is higher at 1-2%.
Amniocentesis is done after 15.5 weeks and involves taking a sample of the amniotic fluid. The risk of pregnancy loss is about 0.5% or 1 in 200.
Bleeding
Bleeding in the first trimester occurs in up to 50% of all pregnancies. It can be associated with a normal on-going pregnancy, or can be the first sign of a miscarriage. Heavy bleeding and cramping will often be associated with miscarriage. If the location of the pregnancy has not yet been determined, one must also be concerned about ectopic (tubal) pregnancy, especially if there is also pain. The situation is typically assessed with a pelvic examination and an ultrasound.
Nausea and Vomiting of Pregnancy (NVP) and Nutrition
Nausea and Vomiting of Pregnancy (NVP)
This is a very common issue in the first trimester. It can continue further into the pregnancy in some cases. Healthlink BC provides helpful suggestions for mild cases.
Diclectin is a medication which is typically taken in the AM, PM, and at bedtime (2 tablets). It can be prescribed by the OB or referring provider.
Severe cases can be associated with dehydration and significant weight loss. The OB will devise a step-wise approach to treatment. In some case, hospital admission may be required.
Nutrition
A general prenatal vitamin with folic acid is advised. Other vitamins or supplements may be recommended in certain circumstances. Healthy families BC has a good review on dietary supplements in pregnancy.
Certain foods pose hazards in pregnancy and should be avoided or consumed in limited quantities. Healthlink BC provides a useful guide.
Self Care
Exercise
Healthy pregnant women are generally encouraged to stay active during pregnancy. Heathlink BC provides useful guidelines. The OB will advise as to any recommended limitations.
Mental Health
Women with pre-existing mental health conditions will often have concerns regarding the effect of pregnancy and the postpartum period on their mental health. They may also have concerns regarding the use of psychiatric medications in pregnancy and postpartum. The OB will provide advice and arrange referral to Reproductive Mental Health, if required.
Immunizations
Women will be informed of advised immunizations. Vaccinations that are safe and recommended during pregnancy include the flu shot (recommended during flu season) and pertussis vaccine or Tdap (given at 27-32 weeks). Boosters of the MMR and varicella vaccines are given postpartum, if required.
Information on Covid-19 vaccination during in pregnancy is evolving rapidly. At present, an individualized discussion of the pros and cons of vaccination between a woman and her OB is recommended.
Planned Mode of Delivery
In most cases, the plan will be for a normal vaginal delivery. Women who have previously delivered by C-section will be counselled on the pros and cons of trial of labour after C-section (TOLAC), if they are eligible, versus elective repeat C-section.
Women who are interested in maternal-choice C-section should mention this to their OB, who will go over the risks and benefits. They can also watch this video prepared by BC Women’s Hospital.
Problem List and Specialist Referrals
At the end of the first visit, the OB will identify specific issues and problems and generate an action list accordingly. This might include further tests and/or referrals to specialists. Common specialist referrals would be to our colleagues in Anesthesiology, OB Internal Medicine, the Diabetes Clinic, and Maternal Fetal Medicine.