OB visits put stress on my pregnancy
November 18, 2010 9:26 AM   Subscribe

Which prenatal visits and tests really matter? I'm pregnant with my second child and a LOT busier than when I had just one. Before I sit down with my doc and she tells me I need to have 1,398 tests and come in roughly every other day, I'd like to be better informed about which visits and tests REALLY make a difference.

Frankly, as much as I like my doc, it seems like many doctors do exactly as much as insurance will let them. Apparently we have fancy insurance. But I don't have a lot of time, and the doctor's office is very far from both home and work. (I've tried to find a closer doc, not an option.)

For example, when calling to schedule the first appointment, the nurse suggested I schedule an ultrasound FIRST (to figure out my inception date), then come in on ANOTHER day for the appointment. And of course I'll need ANOTHER ultrasound at some point after 12 weeks to look at the heartbeat. I can date conception within a month based on when my IUD was removed. So why do two ultrasounds? And why not combine at least some of these appointments?

A few data points:
- I had the full panel of tests (or at least, everything they do to a 32 year old) two years ago, when pregnant with my son. If some tests results don't change, I'd rather not re-do.
- I had a perfectly uneventful pregnancy. He decided to come late, and had to be induced and c-sectioned, but the pregnancy itself was not bad at all.
- I just turned 34. I'm healthy, fit, don't drink, don't smoke, no medications, already taking prenatal vitamins.
posted by anonymous to Health & Fitness (30 answers total) 6 users marked this as a favorite
Millions of women had babies just fine before ultrasounds existed.

I guess the real question, in my mind, would be, if there's something that comes up on the ultrasound that's seriously wrong with your child, would you want to know in advance?
posted by roomthreeseventeen at 9:31 AM on November 18, 2010

I'd do the triple screen, which is usually around 15-18 weeks and an anatomy ultraound around 20 weeks but there's really no need to do ultrasounds. It really just depends on how much information you want.
posted by otherwordlyglow at 9:35 AM on November 18, 2010

I'd suggest you just discuss it with your doctor when you have your first appointment. A little weird that they have doctor appointments and ultrasounds as separate visits, but perhaps that's based on facilities (my dr performed the ultrasounds herself, so they had to be the same visit). Your doctor can tell you which tests carry over (anything genetic for example), and which don't.

I will note that I had less tests and visits for my second baby, partly because they knew how things were probably going to go based on history, and also because my second pregnancy was easier than the first.
posted by Joh at 9:36 AM on November 18, 2010

Well, this is what socialised medicine thinks is a good idea. Do remember that one uneventful pregnancy is no guarantee of another one.
posted by Coobeastie at 9:37 AM on November 18, 2010 [2 favorites]

I'm on my 3rd pregnancy, and lucked into a very hands-off doc this time around. Even though she could classify me as "high risk" because I'm old (39) and fat, she mostly lets me alone. Which is exactly what I want.

I had an ultrasound at 10 weeks to confirm dates, even though I was sure of my LMP, because my cycles have been weird and I wasn't completely sure of possible date of conception. In your case, I'd probably do that, but wait until after you've seen the doc for the first time to make sure it matters. I did have to go to the hospital for a separate ultrasound appointment, because my doctor's office doesn't have ultrasound facilities. But that was at my convenience.

I also did the quad screen, which is a blood draw, and the basic blood panel they do to check for all the usual stuff (disease, anemia, etc). These were done at a regular appointment with the doc. And I had a 20-week anatomy ultrasound, and the 1-hour gestational diabetes test. Because the quad screen was normal, and nothing showed on the ultrasounds, I did not undergo amnio or any other testing.

Everything other than the ultrasounds, though, occurred in conjunction with my regular OB appointments, which are still at every four weeks.

I'd think it reasonable to have the initial visit with the doctor and talk to him/her about a the timeline and scheduling. As I'm sure you know, standard is an office visit ever 4 weeks up to about 32-34 weeks, then every two weeks to about 38 weeks, then every week. Unless there's something unusual or risky going on, or something odd about the practice, they should be able to do everything necessary (except maybe the ultrasounds) in those regular appointments.

This is pretty much also what I experienced with my last pregnancy as well, btw, when we had the crazy gold-plated Cadillac insurance plan and I was seeing an OB/GYN in a much more intense practice, even though we now have much more average-to-good insurance and I'm seeing a family-practice-with-OB doc.
posted by Lulu's Pink Converse at 9:51 AM on November 18, 2010

I was pregnant in a foreign (and developing country) that has socialized medicine.

I asked my American ObGyn what she felt were the essential tests.

I had an early ultrasound for gestation date, the 20 week anatomy ultrasound, the quad screen, and the test where you drink sugar water.

I'd second coobestie's link.
posted by k8t at 10:01 AM on November 18, 2010

Talk to your OB and get his/her answer as well, since there may be things that came up in your last pregnancy that makes some tests important for you, that might not be the case with other women.

FWIW, (warning: don't read if you don't want unhealthy baby stories!) my first pregnancy was reasonably normal and ended with a fantastic healthy baby. My second ended in miscarriage (detected by ultrasound) at 8 weeks. There had been a heartbeat at 6 weeks, but there wasn't enough fluid and the sac was small, so my OB had warned me it might not make it. My third pregnancy, I had a totally healthy heartbeat and no problems. I was nervous after my previous mc, so my doctor scheduled another at 9 weeks mostly (I think) to humor me. It turned out I had again miscarried around 8 weeks, and still hadn't started bleeding. I was travelling and so I wasn't able to schedule a D&C for another week and a half - at which time I not only had still not started bleeding, I also was still experiencing pregnancy symptoms. If I had not had the unnecessary ultrasound at 9 weeks, I would have assumed I was still pregnant and very likely wouldn't have learned the truth until my 1st-trimester scan. So while I understand completely not wanting to get unnecessary tests, be aware that because of the timeline for infant development, anything that you miss could be something you regret not knowing sooner.
posted by Mchelly at 10:03 AM on November 18, 2010 [2 favorites]

If you only do one thing, make it the level II ultrasound at 20 weeks. Even if nothing would change how you proceed with the pregnancy, the ultrasound can give you information that will be important at birth. If you do two things, make it the level II ultrasound and the NT scan / quad screen. The NT scan is a remarkably good predictor of chromosomal abnormalities, particularly when paired with the quad screen, given how noninvasive it is. IMHO, you can easily decline all the early ultrasounds without fear or qualm.

However, they can't re-use your test results from last time. . . those do change with every pregnancy.
posted by KathrynT at 10:03 AM on November 18, 2010

Oh, yeah, and as k8t says, the GDM screen. (Gestational Diabetes.) Undetected or uncontrolled gestational diabetes can have nightmarish effects on neonatal health.
posted by KathrynT at 10:05 AM on November 18, 2010

(just wanted to add, since what happened to me is obviously purely anecdotal and probably (hopefully!) rare, that on the flip side, my SIL went through her pregnancy at roughly the same time that I did, only saw a midwife (not OB) and had no medical tests done at all except the strep test right before delivery. Baby was totally fine.)
posted by Mchelly at 10:06 AM on November 18, 2010

In our experience, midwives are much more relaxed with respect to the tests.

Some unnecessary tests for us, your beliefs may differ:
- STD screening. I mean, why?
- AFP screen. The test result would not have produced actionable information.
posted by RikiTikiTavi at 10:17 AM on November 18, 2010

A few of the tests may be mandatory; my state mandates that all pregnant women be screened, with every pregnancy, for HIV. You may opt out, but opting out means your newborn will be tested as soon after birth as possible, by law.

Most places just roll that into the big blood panel they do early in the pregnancy that also gets mom's blood type, checks rubella antibodies, syphilis exposure, etc. Most of that probably doesn't change between pregnancies for many women, but you're getting the HIV test regardless so you might as well have the full panel.
posted by Eyebrows McGee at 10:24 AM on November 18, 2010

Remember that you have hired your OB. They work for you. You can decide what you want to do and what you don't want to do. Just because they tell you they want to do something, that doesn't mean you HAVE to do it.
posted by rabbitrabbit at 11:07 AM on November 18, 2010

- STD screening. I mean, why?

Because they can be passed to the newborn and do a great deal of damage; curing or temporarily suppressing them is desirable. For example, active herpes is an indication for a c-section.
posted by a robot made out of meat at 11:12 AM on November 18, 2010

I meant to say first-infection HSV. Recurrent HSV you just treat.
posted by a robot made out of meat at 11:14 AM on November 18, 2010

Having been sectioned before, there are a few things that you may need to do differently this time and a few things, if you don't already know, that you should:

The 18-20 week anatomy scan is important because this is the scan where placenta accreta will be noticed, if there is any. Placenta accreta is, in its rarity, more commonly found in women with previous c-sections because the accreta is on the c-section scar. This condition might risk a woman out of a VBAC and it will also require some higher level obstetrical care during a second c-section.

The genetic risks, assuming it is the same father, have probably not increased terribly much, so if you don't want to do them, don't. If you have new information on your family's genetic history than you did two years ago that would be related to issues found upon or after birth, you may wish to have a few of those tests done again. But if not, then don't. If you have a possibility of a particular disorder or issue with that could come up, then it may be worth getting those specific tests done if you want to. If it is a different father (and it doesn't sound like it is), then those tests should be redone.

I happen to think that all of your regularly scheduled-hear-the-heartbeat-get-your-weight-and-blood-pressure appointments are important, so I would definitely make every single one of those, especially when you go to weekly appointments.

If your personal desire is to VBAC, then it is vitally important that you have the appropriate amount of time to discuss this with your doctor and your doctor's views on VBACs. Despite the ACOG changing their position on VBACs as a result of the NIH conference on VBACs this past March, it can be incredibly hard to get an OB to agree to one. So, if you are going for a VBAC, you will need to be armed with your information. I would also suggest a midwife instead of an OB for a VBAC.

If you are going for a repeat c-section, then you may wish to speak with your doctor about options that you may not have had or pursued during your first and presumably unplanned c-section and what you may wish to go a bit differently. This, too, will require the time to have these conversations with your care provider, which is why I personally believe those regular prenatals are so incredibly appointment.

I, too, would skip the early ultrasound and use the date you calculated yourself. And I would not change it based on the 18-20 week ultrasound as the later the ultrasound, the less accurate it is on the due date.
posted by zizzle at 11:14 AM on November 18, 2010

*appointment = important
posted by zizzle at 11:16 AM on November 18, 2010

I notice that no one mentioned a Group B Strep test - this is VERY essential, regardless of what your Group B Strep status was in your last pregnancy.
posted by julthumbscrew at 11:36 AM on November 18, 2010 [2 favorites]

- STD screening. I mean, why?

Because they can be passed to the newborn...

Agreed; a poor choice of words on my part. What I mean is this: for the large population of people who are having a baby and are considered at low risk for STDs (monogamous, etc.)--it seems rather useless. There are of course people for whom that does not apply.
posted by RikiTikiTavi at 11:44 AM on November 18, 2010

"for the large population of people who are having a baby and are considered at low risk for STDs (monogamous, etc.)--it seems rather useless."

Yes, but I think you have to go with the Dr. House answer on this one: Everybody lies. There's a reason my state made HIV testing for pregnant women universal and mandatory -- pregnant women lie about their sex lives, their partners lie about adultery/being on the down low/their other partners, and even if everyone's perfectly honest, diseases can have long incubation times.

People are notoriously dishonest about STDs, even with their doctors, and the risks to the baby are (with some STDs) very high ... but very treatable. So it makes sense to test everyone rather than to ask doctors to try to guess which of their patient who claim to be low-risk are lying.

(Plus I sort-of liked calling my husband and announcing, "Good news! I don't have syphilis!")
posted by Eyebrows McGee at 12:09 PM on November 18, 2010 [9 favorites]

A slightly more detailed breakdown of Coobeastie's NHS information can be found here (direct link to pdf), including on page 22, a whole raft of antenatal interventions which are not routinely recommended.
posted by dogsbody at 12:31 PM on November 18, 2010

An ultrasound is not necessary at any point in the pregnancy. In a similar situation to you with our second child, my wife had a single blood draw, a blood-glucose test and monitoring of fetal growth and heart tones with a doppler and palpation.
posted by putzface_dickman at 12:39 PM on November 18, 2010

Strep B! I got tested at 36 weeks and my son still contracted bacterial meningitis and was very sick. This time (I'm nearly 35 weeks) I'll be pushing to get tested either later or twice.

But I go to a pretty minimal practice, I had to opt-in for a 12-week nuchal fold scan and blood test at the same time, but some women choose to forgo that. Then there's the triple or quad scan sometime between 15-20 weeks, then one anatomy scan/gender ultrasound, the diabeetus test, and the strep B. So 3 separate trips from your monthly visits, most likely.

And yeah, I had to schedule ultrasounds at different times from my appointments too, although my practice is now getting better at doing them one after another. Before, they were farming it out to third-party ultrasound companies.
posted by kpht at 1:53 PM on November 18, 2010

You might find Dr. Sarah J Buckley's Gentle Birth, Gentle Mothering useful -- it exhaustively details all of the usual prenatal tests & procedures, as well as those used in labour & birth, and the benefits and risks of each one.
posted by sea change at 2:37 PM on November 18, 2010

In Australia, what's routine ultrasound-wise is a 12 week nuchal translucency scan/blood test and an anatomy scan at 18-20 weeks. I'm not a doctor or a sonographer/ultrasound technician, but I am medical admin staff, and I have heard both of those types of people talking about why those scans are important.

On the 12 week scan/blood test, things can come up which indicate risk for heart problems or fetal growth problems later, in addition to risks for chromosomal abnormalities, so the opinion I've heard is that even if, say, you don't want to know about chromosomal abnormalities, you should still have the scan. (And by the way, people with one or more normal baby might still have a high risk on a later pregnancy.)

But I think dating scans can be replaced by blood tests--I know GPs sometimes estimate date of delivery clinically, and AFAIK that's based on blood test results. So you might be able to skip that initial dating ultrasound. Hopefully when you talk to your doctor, s/he will be happy to take the approach you want...
posted by equivocator at 5:01 PM on November 18, 2010

Having known several perfectly healthy women whose pregnancies turned on a dime (we're talking about those scary syndromes found in the back of What to Expect), I think it is really nice to know those things ahead of delivery, which makes it so much safer for both the mother and the baby. If you've never faced a situation where your own health is at stake because of a pregnancy-related problem, it's hard to fathom this, but thank goodness for modern medicine.

However, you can absolutely insist on combining certain things in the same appointment. I have done this, just by telling them that it would be too hard for me to leave work to have an in-house ultrasound one day and an in-house blood draw 2 days later.
posted by Knowyournuts at 7:32 PM on November 18, 2010

Many of the tests mentioned above, especially the first trimester screenings to evaluate risk for fetal chromosome anomalies, are dependent upon accurate gestational age and number of fetuses. Therefore, in order to ensure these tests are done at the proper time and are properly interpreted, an early sonogram may be needed, if you can only "date conception within a month based on when (your) IUD was removed." Dating by hormones is only accurate relatively early in gestation.
posted by beaning at 9:05 PM on November 18, 2010

I agree with getting the 20 week ultrasound, sugar test, Strep B, and DEFINITELY the recommended once a month and eventually once every two week check-ups. Getting your urine checked, baby's heartrate, and your blood pressure can prove to be incredibly valuable. During my first pregnancy, everything was absolutely perfect, and I felt GREAT the entire time. Went in for my 37 week visit (still feeling incredible), only to discover that my blood pressure was something like 160/100 and I was spilling protein. I ALMOST rescheduled that appointment, and am so so grateful that I didn't. I ended up with preeclampsia and full-blown HELLP syndrome, and had to have an emergency c-section. The regular prenatal care can definitely catch things early on, and make a potentially VERY complicated situation less complicated. It did for me, at least.
posted by I_love_the_rain at 11:17 PM on November 18, 2010

I'm glad I had a routine u/s at 7w, otherwise we wouldn't have known we were having (spontaneous) triplets. You just never know.

That said, if you don't want the ultrasounds and tests and all that, then talk to your doctor about it.
posted by pyjammy at 7:49 AM on November 19, 2010

I'd also suggest getting an electronic blood pressure cuff and monitoring it youself, and talk to your doctor if your BP goes up closer to the end of the pregnancy. this can be a sign on Preeclampsia
posted by jrishel at 12:32 PM on November 19, 2010

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