Pregnancy Changes and The First Prenatal Visit

first nurse visit pregnancy

Pregnancy is a transformative and exciting journey that brings profound physical and emotional changes for expectant mothers. As nursing professionals, understanding and addressing these changes is essential in providing comprehensive care during pregnancy. The first prenatal visit holds immense significance as it sets the foundation for a successful pregnancy journey, ensuring optimal maternal and fetal well-being through early detection, education, and tailored care plans.

This article aims to serve as a comprehensive nursing guide, focusing on the common pregnancy changes experienced by women and the critical aspects of the first prenatal visit. This serves as a valuable resource, equipping nursing professionals with the knowledge and skills necessary to provide comprehensive care, support, and education to women embarking on the beautiful journey of pregnancy.

Table of Contents

Presumptive signs, probable signs, positive signs, reproductive system changes, breast changes, integumentary system, respiratory system, cardiovascular system, gastrointestinal system, urinary system, skeletal system, endocrine system, mood swings, changes in sexual desire, introversion/extroversion, social changes, cultural changes, family changes, individual changes, first trimester: accepting the pregnancy, second trimester: accepting the baby, third trimester: preparing for the baby, breast tenderness, palmar erythema, constipation, nausea, vomiting, pyrosis, muscle cramps, hypotension, varicosities, hemorrhoids, heart palpitations, frequent urination, ankle edema, braxton hicks contraction, recommended weight gain, energy needs, protein needs, vitamin needs, mineral needs, fluid needs, fiber needs, healthy signs of good nutrition, health history, demographic data, chief concern, history of past illnesses, history of family illnesses, social profile, gynecologic history, obstetric history, systemic assessment.

  • Papanicolaou Smear (Pap smear)

Blood Studies

Glucose tolerance test, ultrasonography, preconception classes, expectant parenting classes, sibling education classes, breastfeeding classes, preparation for childbirth classes, the bradley method, the dick-read method, the lamaze method, the appropriate setting, the birth attendant and support person, hospital birth, alternative birthing centers, physiological changes in pregnancy.

A woman certainly undergoes a lot of changes during pregnancy. Some gain changes permanently, others have changes that are very subtle. These changes, however, are welcomed by mothers with open arms because they are signs that a new life is being formed inside of her.

The Diagnosis of Pregnancy

Before a pregnancy is confirmed, the woman might see small and big changes in her body that could help in determining if she is already pregnant.                               

Presumptive signs are signs that are least indicative of a pregnancy. These changes can only be felt by the woman but cannot be documented by the healthcare provider.

  • Breast changes (swollen), nausea and vomiting , amenorrhea, frequent urination , fatigue , uterine enlargement, quickening , linea nigra, melasma, and striae gravidarum are the presumptive signs of pregnancy.
  • However, these signs may also denote other conditions that the body is undergoing.

Probable signs of pregnancy are objective and can be seen primarily by the healthcare provider. These can be taken through laboratory tests and home pregnancy tests by detect the presence of human chorionic gonadotropin in the blood or in the urine .

  • Chadwick’s sign or a change in the color of the vagina from pink to violet is a probable sign of pregnancy.
  • Goodell’s sign is a probable sign that depicts a softening of the cervix.
  • Hegar’s sign is the softening of the lower uterine segment.
  • Ballottement is described as the rise of the fetus felt through the abdominal wall when the uterine segment is tapped on a bimanual examination.
  • An evidence of a gestational sac found during ultrasound is another probable sign.
  • Braxton-Hicks contractions are periodic uterine tightening and contractions.
  • The fetal outline can also be now palpated by the examiner through the abdomen.

There are only three positive signs of pregnancy that are documented by the health care providers.

  • Evidence of a fetal outline on ultrasound.
  • With the use of a Doppler, an audible fetal heart rate is another positive sign.
  • The last is fetal movement felt by the healthcare provider.

The system that will greatly feel the changes is the reproductive system. It includes the ovaries, uterus, and vagina.

  • On the first trimester in the ovaries, the corpus luteum starts to become active. By the second trimester, it begins to fade until the third trimester where it has already disappeared.
  • The uterus increases in growth starting from the first trimester. On the second trimester, the placenta is forming estrogen and progesterone .
  • The vagina undergoes changes during the first trimester wherein a whitish discharge is present. From the second until the third trimester, the whitish discharge increases in amount.
  • Amenorrhea also occurs, or the absence of menstruation .
  • The cervix undergoes a more vascular and edematous appearance owing to the increased level of estrogen.
  • Breast changes start from the first trimester as the woman feels tenderness and fullness of her breasts.
  • As the pregnancy progresses, the breast size increases a size or two, as the mammary alveoli and fat deposits increase in size.
  • The areola of the nipples become darker and its diameter increases.
  • The vascularity of the breast also increases, as evidenced by the prominent blue veins over the surface.
  • The Montgomery’s tubercles or the sebaceous glands of the areola protrudes and enlarges.

Systemic Changes

After the changes that occurred mainly in the reproductive system of a pregnant woman, systemic changes will also start to occur in different body systems.

  • The stretching of the abdomen causes rupture of the small segments of the connective layer of the skin.
  • Striae gravidarum or pinkish to reddish marks on the sides of the abdominal wall are the result of the rupture.
  • Linea nigra is a narrow, brown line that runs from the symphysis pubis to the umbilicus and separates the abdomen into right and left hemispheres.
  • Melasma or chloasma (mask of pregnancy) refers to the darkened areas on the cheeks or the nose that may appear during pregnancy.
  • Telangiectasis is red, branching spots that can be seen on the thighs. It is also called as vascular spiders.
  • Palmar erythema also occurs because of the increase in the estrogen level of the pregnant woman.
  • A pregnant woman usually experiences stuffiness or marked congestion because of the increasing estrogen levels.
  • Shortness of breath is also a common discomfort of pregnancy as the pregnant uterus pushes the diaphragm upward.
  • The total oxygen consumption of a pregnant woman increases by 20%.
  • The blood pressure of the pregnant woman decreases in the second trimester and then returns to its prepregnancy level on the third trimester.
  • The cardiac output increases 25% to 50%.
  • Plasma volume also increases up to 3600 mL, marking the condition called pseudoanemia early in the pregnancy.
  • Heart rate also increases to 80 to 90 beats per minute.
  • The blood volume increases up to 5,250 mL during pregnancy.
  • Nausea and vomiting is one of the first signs of pregnancy that a woman feels.
  • Slower intestinal peristalsis occurs during the second trimester of the pregnancy which causes heartburn, flatulence, and constipation .
  • Hemorrhoids also occur from the increased pressure of the uterus on the veins in the lower extremities.
  • The total body water of a pregnant woman increases up to 7.5 L for a more effective placental exchange.
  • Even when the woman has an increased urine output, her potassium levels are still adequate due to progesterone, which is potassium -sparing.
  • The bladder capacity increases to accommodate 1,000 mL of urine during pregnancy.
  • On the first trimester, the frequency of urination already increases. By the last two weeks of pregnancy it reaches up to 10 to 12 times per day.  
  • By the 32 nd week of pregnancy, the symphysis pubis widens for 3 to 4 mm.
  • The center of gravity of a pregnant woman changes, and to make up for it she tends to stand straighter and taller than usual and with the abdomen forward and the shoulders thrown back, the ‘pride of pregnancy’ or commonly ‘lordosis’ occurs.
  • A slight enlargement in the thyroid and parathyroid gland increases the basal metabolic rate of a pregnant woman and for better consumption of calcium and vitamin D.
  • Thyroid hormone production increases.
  • The insulin produced from the pancreas decreases early in the pregnancy, thereby increasing glucose available for the fetus.
  • Increase in insulin occurs in the first trimester because estrogen, progesterone and HPL have insulin antagonistic properties.
  • FSH and LH decreases causing anovulation .
  • As the breasts are prepared for lactation, prolactin increases in production.
  • The increase in melanocyte-stimulating hormones causes increase in skin pigment.
  • The human growth hormone increase to aid the fetus in growing.
  • Estrogen and progesterone aids in uterine and breast enlargement.
  • Human placental lactogen increases glucose levels to supplement the growing fetus.
  • Relaxin increases to soften the cervix and collagen of joints.

The changes in the physiologic status of a pregnant woman are just one of the many phases of changes that occur during pregnancy. Most of these are normal, but when the pregnant woman experiences an excessive manifestation of these signs, it would be best to consult your healthcare provider.

Psychological Changes in Pregnancy

The various changes that a woman undergoes during pregnancy entirely sweep the entirety of the human body. Almost every aspect is altered, hormones get together to create a whole new modifications in the mind, the body, and the emotions. Psychological aspects would also be given a new perspective as it also alters together with the rest of the woman’s body.

How a Woman Responds to Pregnancy

Mood swings, grief , changes in sexual desires, and stress are only some of the psychological changes that a pregnant woman experiences. The couple might misinterpret these changes, so health education must be integrated in the care of the pregnant woman.

  • Grief may arise from the realization that one’s roles would be changed permanently.
  • A pregnant woman would be weaned off her role as a dependent daughter, or as a happy-go-lucky girl, or a friend who is always available.
  • Even the partner would have to leave the roles or the life he has been accustomed to as a man without a child to support.
  • Also known as emotional lability, this psychological reaction can be caused by two factors: hormonal changes or narcissism.
  • The comments that she had brushed off in her nonpregnant state can now touch a nerve or hurt her.
  • Crying is a common manifestation of mood swings, during and even after the pregnancy.
  • Women who are on the first trimester of pregnancy experience a decrease in libido mainly because of breast tenderness, nausea, and fatigue .
  • On the second trimester, sexual libido may rise because of increased blood flow to the pelvic area that supplies the placenta.
  • The third trimester might bring an increase or decrease in sexual libido due to an increase in the abdominal size or difficulty in finding a comfortable position.
  • Estrogen increase may also affect sexual libido as it may bring a loss of desire.
  • The couple must be informed that these changes are normal to avoid misunderstanding the woman’s attitude.
  • Pregnancy is a major change in roles that could cause stress.
  • The stress that a pregnant woman feels might affect her ability to decide.
  • The discomforts that she may feel could also add up to the stress she is experiencing.
  • Assess whether the woman is in an abusive relationship as it may contribute further to the stress.
  • Introversion refers to someone who focuses entirely on her own body and a common manifestation during pregnancy.
  • Some pregnant women also manifest extroversion, or acting more active, healthier and more outgoing than before their pregnancy.
  • Extroversion commonly happens to women who had a hard time conceiving and finally hit jackpot.
  • In the past, a pregnant woman is isolated from her family starting from visiting for prenatal consultation until the day of birth.
  • She is isolated from her family and the baby a week after birth.
  • Today, having a support system for pregnant women is highly encouraged, like bringing along someone to accompany her during prenatal visits and allowing the husband to be with the wife during birth if he chooses to.
  • Opinions on teenage pregnancy, late pregnancies, and having the same sex parents are now widely accepted compared to being taboos in the past.
  • A pregnant woman’s culture and beliefs may also greatly affect the course of her pregnancy.
  • Assess if the woman and her partner have particular beliefs that might affect the way the take care of the pregnancy so you can integrate them in your plan of care.
  • Despite the modern ages, there are still groups who firmly believe in their culture’s explanations about birth complications and the health care providers must respect this.
  • Myths that surround the pregnancy should always be respected, but the couple should be educated properly regarding what could be dangerous for the fetus’ health.
  • The environment where the woman grew influences the way she would perceive her pregnancy.
  • Family culture and beliefs also affect a woman’s perception of pregnancy.
  • If she is loved as a child, she would have an easy time accepting her pregnancy compared to women who were neglected by her family during childhood.
  • A woman who has been told of disturbing stories about giving birth and pregnancy would view her own in a negative light, while those who grew with beautiful birth stories would more likely be excited for their pregnancy.
  • A positive attitude would only result from a positive outcome and influence from the woman’s own family.
  • Becoming a new mother is never an easy transition. The woman must first be able to cope with stress effectively, as this is a major concern during pregnancy.
  • She needs to have the ability to adapt effectively to any situation, especially if the pregnancy is her first because there might be a lot of new situations that would arise.
  • Her ability to cope with a major change and manage her temper would be put to a test during motherhood.
  • The woman’s relationship with her partner also affects her ability to accept her pregnancy easily.
  • If she feels secure with her relationship with the father of her child, she would have an easier time accepting her pregnancy as opposed to an unstable relationship where she feels insecure and may doubt the decision of keeping the pregnancy.
  • A woman who feels that the pregnancy may rob her of her looks, her freedom, a promotion, or her youth would need to have a strong support system so she could express her feelings and unburden her chest.
  • The father’s acceptance of the pregnancy also influences the woman’s ability to accept the marriage.
  • Utmost support from her husband would be very meaningful for the woman especially during birth.

The Psychological Tasks of Pregnancy

Both the woman and her husband walk through a tangle of emotions during pregnancy. Accepting that a new life would be born out of your blood is not as easy as others may think. There are several stages that both should undergo, the psychological way.

  • The shock of learning about a new pregnancy is sometimes too heavy for a couple, so it is just proper for the both of them to spend some time recovering from this major life-altering situation and avoid overwhelming themselves at first.
  • One of the most common reactions of a couple who would be having a baby for the first time is ambivalence, or feeling both pleased and unhappy about the pregnancy.
  • The woman and her partner will start to merge into the role of novice parents as second trimester closes in.
  • Emotions such as narcissism and introversion are commonly present at this stage.
  • Role playing and increased dreaming are activities that help the couple embrace their roles as parents.
  • At this stage, the woman and her partner must start to concentrate on what it will feel like to be parents.
  • The couple starts to grow impatient as birth nears.
  • Preparations for the baby, both small and big, takes place during this stage.
  • The baby’s clothing and sleeping arrangements are set and the couple is excited for his arrival.

The transition of a woman from the start until the end of the pregnancy is a big turning point for her and the people who surround her. Every single one of them must be prepared physically, mentally and emotionally because pregnancy is also considered a crisis in life; something that could turn your world upside down.

Discomforts of Pregnancy

Pregnancy ultimately builds up a woman. It is the pinnacle of life wherein women become more than just women; they become mothers. The journey of pregnancy is also a tough one but is meaningful and wonderful. The discomforts a woman would undergo are just bumps along the road of fulfillment once she has delivered her child.

Discomforts during the First Trimester

There are a number of discomforts that can be felt during the first trimester. This is the time when the body is just starting to adjust to the pregnancy, and hormones are still in chaos. The woman must be educated on how to ease these discomforts to help her adjust slowly.

Breast tenderness is one of the first symptoms that the woman would notice in early pregnancy. The tenderness may vary between women; some hardly notice the sensation at all.

  • Advise to wear a bra with a wide shoulder strap.  The support it gives helps ease the tenderness.
  • Dress warmly and avoid cold. She should also dress warmly as exposure to cold increases the tenderness.
  • Get examined. Women who experience intense pain should have to examine the presence of nipple fissures or breast abscess to rule out these conditions.

Palmar erythema is the constant itching and redness of the palms but is not considered an allergy . Increased estrogen levels possibly cause the pruritus.

Palmar erythema. Image via thebileflow.wordpress.com

  • No it’s not an allergy .  Educate the woman that she has not developed an allergy, and this is normal during pregnancy.
  • Calamine lotion to the rescue.  To soothe the itchiness, calamine lotion can be applied.
  • Disappears naturally.  Palmar erythema would naturally disappear once the body has adjusted to the increased estrogen levels.

Constipation is caused by slow peristalsis due to the pressure from the growing uterus.

  • Increase fiber in the diet.  Encourage the woman to move her bowels regularly and increase the fiber in her diet.
  • Drink water.  Advise her to drink at least 8 to 10 glasses of water every day.
  • Iron supplements.  Educate her that iron supplements can cause constipation but need not be stopped because it helps build up fetal iron stores.
  • Don’t use mineral oil.  The use of mineral oil to relieve constipation is not advisable because it absorbs the fat-soluble vitamins A, D, K, and E.
  • Don’t use enemas.  Enemas are also prohibited as it may initiate labor .
  • So as OTC laxatives.  Over-the-counter laxatives are also contraindicated unless prescribed.
  • Avoid gas-forming foods.  Advise the woman to avoid gas-forming food to prevent excessive flatulence.

Nausea and vomiting are also one of the earliest symptoms of pregnancy. Pyrosis or heartburn typically occurs when the woman ate a large meal.

  • Small frequent feedings. Advise the woman to take small, frequent meals and avoid greasy foods.
  • Upright position after. Encourage her to keep in an upright position after meals to avoid reflux.

Pregnant women experience fatigue mostly in early pregnancy because of increased metabolic requirements .

  • Rest and sleep . Advise her to increase the amount of rest and sleep and to continue with her normal nutrition intake.
  • Take short breaks. For women who still work, advise her to take short breaks, especially if her work involves being up and about the whole day.

Muscle cramps are caused by decreased serum calcium levels, increased phosphorus levels, or interference in the circulation.

  • Lie down. Advise the woman that when this happens, she should lie on her back and extend the affected leg while she keeps her knee straight and dorsiflexes the foot.
  • Magnesium citrate or aluminum hydroxide gel. Magnesium citrate or aluminum hydroxide gel is prescribed to women who have frequent and unrelieved muscle cramps.
  • Raise those feet. The woman should elevate her lower extremities frequently to promote circulation.

Avoid During Pregnancy

When the woman lies on her back and the uterus presses upon the vena cava , supine hypotension might occur, impairing blood return to the heart.

  • Sleep sideways. Advise woman to rest or sleep on her side, not on her back.
  • Rise slowly. Encourage her to rise slowly and dangle feet over the bed for a few minutes; avoid standing for extended periods.

Varicosities are tortuous veins caused by the pressure of the uterus to veins at the lower extremities.

  • Raise legs. Advise the woman to rest in Sim’s position or on the back with the legs raised against the wall.
  • Don’t cross legs. Discourage sitting with legs crossed or knees bent and the use of constrictive knee-high hose or garters.
  • Support stockings do wonders. The use of elastic support stockings is advised to relieve varicosities.
  • Exercise and walk. Exercise is also effective through taking walk breaks from chores or from standing or sitting for too long.
  • Vitamin C helps. Vitamin C is also recommended to reduce varicosities for the formation of blood vessel collagen and endothelium.

Hemorrhoids are varicosities of the rectal veins that occur because of the pressure of the veins from the weight of the uterus.

  • Evacuate daily. Advise the woman to evacuate her bowels daily and resting on a Sim’s position.
  • Knee-chest position . Encourage the woman to assume a knee-chest position for 10-15 minutes at the end of the day to relieve the pressure on the rectal veins.
  • Stool softener. If the woman already has hemorrhoids , a stool softener would be recommended.
  • Relieving hemorrhoids. The pain of hemorrhoids could also be relieved by applying witch hazel or cold compresses to external hemorrhoids.

Heart palpitations may occur when upon sudden movement the woman experiences bounding palpitation of the heart. This is mainly due to circulatory adjustments necessary to accommodate her increased blood supply during pregnancy.

  • Slow and steady. Advise the woman to move in slow, gradual movements to prevent heart palpitations.

The pressure of the uterus on the bladder causes frequent urination . Frequency occurs early in the pregnancy and late in the pregnancy.

  • No fluid restriction. Advise the woman not to restrict her fluids to diminish the frequency of urination, instead; caffeine intake should be diminished.
  • Offer assurance. Assure the woman that voiding frequently is a normal occurrence during pregnancy.
  • Kegel’s exercises. Kegel’s exercise also helps to reduce the incident of stress incontinence and helps regain the strength of urinary control and strengthens perineal muscles for birth.

Discomforts during the Second and Third Trimester

The last trimesters of pregnancy also have their set of discomforts that you have to differentiate from complications that might arise.

Lumbar lordosis develops as pregnancy progresses to maintain the balance.

  • Low heels. Advise the woman to wear shoes with low to moderate heels to reduce the amount of spinal curvature necessary to maintain an upright position.
  • Warm compress. Backache can be relieved by applying local heat on the area.
  • Body mechanics. Advise the woman to squat rather than bend over to pick up objects.
  • Close to center of gravity. Advise the woman to lift objects by holding them close to the body.

Dyspnea results from the pressure of the expanding uterus on the diaphragm. Dyspnea is prominent especially when the woman lies flat on the bed at night.

  • Proper sleeping position. Encourage the woman to sleep with her head and chest elevated.
  • Limit activities. Advise her to limit her activities during the day to prevent exertional dyspnea .

Late in pregnancy, some women experience swelling of the ankles and feet. The edema is caused by general fluid retention and reduced blood circulation in the lower extremities.

  • Watch out for proteinuria or eclampsia . Assess if the woman has hypertension or proteinuria to rule out eclampsia.
  • Sleep on the left side.  Advise the woman to lie on her left side when resting or sleeping.
  • Sit. Encourage her to sit half an hour in the afternoon and in the evening with legs elevated and to avoid constrictive clothing.

From the 8 th to the 12 th week of pregnancy, the uterus periodically contracts and relaxes, and this is termed as Braxton Hicks contraction.

  • Give assurance. Assure the woman that these are not signs of early labor , but they can inform their healthcare provider about them.

A pregnant woman would always want reassurance that her pregnancy is healthy. These discomforts may alarm her, especially if she knows little about the physiology of pregnancy, so it is the role of healthcare providers to guide her and be there for her whenever she needs them throughout the pregnancy.

Nutritional Health During Pregnancy

One of the most important aspects in pregnancy is the woman’s nutritional status . Despite the discomfort she may feel towards eating early in pregnancy, she should never take her nutrition for granted because of the life that is dependent inside of her.

  • An average weight gain during pregnancy is 11.2 to 15.9 kg or 25 to 35 lbs.
  • For a more precise estimation of adequate weight gain, compute using the body mass index , which is the ratio of weight to height.
  • Weight gain during pregnancy occurs due to fetal growth and accumulation of maternal stores.
  • On the first trimester, approximately 0.4 kg or 1 lb per month weight gain is recommended.
  • On the last two trimesters, a weight gain of 0.4 kg or 1 lb per week is recommended.
  • Excessive weight gain occurs with 3 kg or 6.6 lbs of weight gain per month during the last two trimesters.
  • A weight gain of less than 1kg or 2.2 lbs in the second and third trimesters is less than usual.

Nutrition for the Pregnant Woman

  • The DRI or Dietary Reference Intake of calories of women of childbearing age is 2200.
  • For pregnant women, an additional of 300 calories for a total of 2500 calories is recommended.
  • This addition in calories provides more energy to the fetus and an elevated metabolic rate to the woman.
  • Advise woman to obtain calories from complex carbohydrates like cereals and grains because these are digested more slowly to regulate glucose and insulin .
  • Encourage women to prepare healthy snacks such as carrot sticks, cheese, and crackers at the start of the day.
  • Assess the weight that the woman is gaining so you can determine if the woman’s caloric intake is adequate.
  • Advice the woman not to restrict caloric intake as the fetus is rapidly growing in the final weeks.
  • The DRI for protein in women is 46g/d.
  • If protein needs are met, overall nutritional needs are met as well except for vitamins C, A, and D.
  • Vitamin B12 is found in animal protein; therefore inadequate protein means vitamin B12 deficiency.
  • Complete protein or protein that contains the nine essential amino acids can be found in meat, poultry, fish, eggs, yogurt, and milk.
  • Incomplete protein or the protein that does not contain all essential amino acids comes from non animal sources.
  • When the woman has a history of hypercholesterolemia, advise her to consume lean meat, olive oil, and to remove the skin from poultry.
  • Milk is also a rich source of protein, and for women who are lactose intolerant, she can add lactase supplement, take calcium supplements, or buy lactose-free milk.
  • Yogurt or cheese can also be a substitute for milk.
  • Linoleic acid is a fatty acid that cannot be manufactured by the body and must therefore be obtained from other sources.
  • Vegetable oils such as olive, corn, and safflower contains linoleic acid that must be consumed by the pregnant woman.
  • Advise the woman to avoid animal fats such as butter.
  • Encourage intake of omega-3 oils found in fish, omega-3 fortified eggs, and spreads.
  • Vitamin D which is essential for calcium absorption, when lacking in a pregnant woman would result to diminished maternal and fetal bone density.
  • Lack of vitamin A results in tender gums and poor night vision .
  • Advise the woman to consume plenty of fruits and vegetables and her daily prenatal vitamins to meet the daily vitamin intake requirements.
  • Advise the woman not to use mineral oils as laxative because it prevents the absorption of fat-soluble vitamins.
  • Folic acid is important for the production of red blood cells and can be found mostly in fresh fruits and vegetables.
  • Calcium and phosphorus is needed for bone and teeth formation and should be consumed by the pregnant woman.
  • The woman needs to ingest iodine for the proper functioning of the thyroid gland, and it is most commonly found in seafood.
  • The DRI for iron for pregnant women is 27 mg, so the woman must ingest foods rich in iron and iron supplements to build more hemoglobin for the fetus.
  • Sodium maintains fluid in the body, so it is advisable for the pregnant woman to continue adding salt into her food if not restricted.
  • Advise the woman to drink extra amounts of water to promote kidney function.
  • Encourage intake of 2 to 3 glasses of fluid daily over three servings of milk.
  • To prevent constipation, encourage the woman to eat plenty of fruits and green, leafy vegetables to provide fiber.
  • Fiber can also lower cholesterol levels and removes carcinogenic contaminants from the intestine .
  • The hair is shiny and strong with good body.
  • The woman has good eyesight especially at night; the conjunctivae are moist and pink.
  • There are no cavities in the teeth, no swollen or inflamed gingiva, no cracks or fissures at the corners of the mouth , the mucous membranes are moist and pink, the tongue is smooth and non tender.
  • The neck has a normal contour of the thyroid gland.
  • The skin is smooth with normal color and turgor, no ecchymosis and petechiae present.
  • The extremities have a normal muscle mass and circumference; normal strength and mobility , and edema are minimal.
  • The fingernails and toenails are smooth, pink, and normal in contour.
  • The weight should be within normal limits of ideal weight before the pregnancy.
  • The blood pressure is within normal limits for length of pregnancy.

The woman must stay healthy through the entirety of her pregnancy, and most of the nutrients she needs come from food sources. Proper health and nutrition education should be discussed by the healthcare provider to ensure that the pregnant woman is getting the right amount of nutrients that she and the fetus needs.

First Prenatal Visit

The pregnant woman’s first prenatal visit should be the building block of a healthy, happy pregnancy. Everything is established during the first visit, such as the assessment , whether the pregnancy is confirmed, and a little bit of planning for the future. It’s time to focus on the woman herself and the details that could make or break her pregnancy glow.

Initial Interview

  • The first prenatal interview could take a long time, so the person who is scheduling appointments for the visits should make the woman aware to avoid cancelling of appointments or rushing of the interview because the woman has an errand to attend to.
  • It is important that the healthcare provider should establish rapport even on the first visit because information such as what the woman feels about her pregnancy and if she has any fears can only be taken once the woman trusts her healthcare provider.
  • Personal interviews can also make the woman feel important and that she is not just one of the patients that would immediately be forgotten after the visit.
  • The interview must take place in a private, quiet environment because it would be difficult for the woman to answer all the questions when you are in a sitting room full of waiting patients or on the hallway.
  • The woman must also understand your role in the assessment , because if she views you only as the interviewer you would only get superficial information from her.
  • One of the purposes of the initial interview is to assess the health history of the pregnant woman.
  • Establishing a baseline health data is crucial especially when there is a new symptom that arises from the woman and it could only be identified as new based on the data gathered from her health history.
  • The demographic data are the superficial data that can be obtained from the woman.
  • These include the name, age, address, telephone number, and health insurances.
  • The chief concern of the woman when she visits the clinic is she thinks she might be pregnant.
  • Assess the first day of the last menstrual period of the woman.
  • Assess any early signs of pregnancy such as nausea and vomiting , fatigue , and breast tenderness.
  • Inquire if she has tried any home pregnancy test kit or had a pregnancy test from a clinic to establish her pregnancy.
  • It is important to assess any past illness because it might become active during or after the pregnancy.
  • Assess if there are any infections from the past, especially sexually transmitted diseases so you could educate the woman and suggest any vaccines available.
  • There are vaccines that are not friendly for a pregnant woman; however, vaccines such as influenza and poliomyelitis can be administered.
  • Assess any allergies present even before pregnancy to avoid triggers that could also affect the fetus.
  • Assess the presence of family illnesses such as hypertension , diabetes , or asthma on both the father and mother.
  • There are illnesses that could become a potential problem during pregnancy or one that could be transferred to the fetus.
  • Assess the woman’s current nutrition profile, or ask her to have a 24-hour recall to obtain nutrition information.
  • Assess the frequency, type, and amount of exercise she does to determine if her pattern of activities is still recommended during pregnancy.
  • Assess if the woman smokes or drinks, its frequency, and amount because these vices could cause fetal alcohol syndrome or preterm birth.
  • Assess history of medication intake and what medication the woman is taking during pregnancy to determine its possible effects on the fetus.
  • Obtain the age of the woman’s menarche, her usual cycle, the duration, and the amount of menstrual flow.
  • Assess any past reproductive tract surgery as it can affect the present pregnancy, such as tubal surgery from ectopic pregnancy .
  • Assess the reproductive planning method that the woman used or will be using after pregnancy, and also her sexual history to educate her about safe sex practices.
  • Assess the woman’s pregnancy history using GTPALM .
  • G is the gravid classification or the number of times the woman became pregnant.
  • T is the number of full term infants born.
  • P is the number of preterm infants born.
  • A is the number of miscarriages or therapeutic abortions.
  • L is the number of living children .
  • M refers to multiple pregnancies.
  • Assess the woman’s respiratory system , if she is currently experiencing cough , asthma , pain upon breathing, or any serious respiratory illnesses such as tuberculosis .
  • Assess the cardiovascular system and any history of heart murmurs, heart diseases, hypertension , and if she knows her blood pressure level and any experience of blood transfusion .
  • Assess her gastrointestinal system ; ask about her pre-pregnancy weight, any discomforts such as vomiting , diarrhea or constipation, hemorrhoids, and changes in bowel habits.
  • Assess her genitourinary system and ask about any urinary tract infections, STIs, PIDs, any difficulties in conceiving, and hematuria .
  • Assess any breast lumps, secretions, pain upon palpation of the breast, or tenderness.
  • Assess the woman’s last dental exam, the use of any dentures, the condition of the teeth, and if she is experiencing any difficulty in swallowing.

Laboratory Assessment

Papanicolaou smear (pap smear).

  • Pap smear is performed to detect and diagnose the presence of precancerous and cancerous conditions of the cervix, vulva, or vagina.
  • The test also reveals infectious diseases and inflammation.
  • The classification of Pap smear can be seen in the Bethesda classification of Pap smears.
  • Women who have multiple sexual partners, smoke cigarettes, have a history of HPV, and sexually active before 21 years old should have Pap smear done more frequently.
  • Complete blood count should be taken to assess the hemoglobin, hematocrit, and red cell index and determine the presence of anemia .
  • White blood cell count and platelet count must also be obtained to assess for infection clotting ability.
  • Blood typing with Rh factor is also important because blood needs to be available if ever the woman experiences bleeding during pregnancy.
  • Maternal serum alpha fetoprotein detects birth defects such as neural tube defects if elevated and chromosomal anomalies if decreased.
  • Antibody titers for rubella and hepatitis B or HBsAG determine whether the woman is protected against rubella and if the newborn would have a chance of developing hepatitis B.
  • A woman with a history of diabetes , large for gestational age babies, obese, or has glycosuria should undergo glucose tolerance test.
  • A 50-g oral toward the end of the first trimester should be performed to rule out gestational diabetes .
  • The plasma glucose level should not exceed 140mg/dl at 1 hour.
  • Urinalysis is performed to assess proteinuria, glycosuria, and pyuria.
  • These can be done through test strips or microscopic examination of the urine.
  • To confirm pregnancy, an ultrasound must be scheduled especially if the woman is unsure of the date of her last menstrual period.
  • Ultrasonography would also determine the growth of the fetus, but only the gestational sac would be seen at this stage.

Childbirth Education

Most expectant parents, especially the first timers are eager yet anxious to know the rules to becoming a parent even before the birth of their child. There are several courses or classes for parents regarding childbirth that would fill up the gap of knowledge that the couple is yearning for.

  • The birth of childbirth education started in the early 1900s to encourage women to involve themselves in prenatal care .
  • It progressed because of the additional birth choices that emerged later on.
  • The goal of childbirth education is to prepare expectant parents physically, mentally, and emotionally for childbirth.
  • Childbirth educators have a professional degree and a certificate from a childbirth education course.
  • Some of the topics that childbirth educators teach are the physical and emotional aspects of pregnancy, early parenthood and coping skills, and labor support techniques.
  • Childbirth classes are mostly taught in group; and today there are instructors who also employ the use of slides, videotapes, and demonstrations.
  • Childbirth education is more effective if both the parents are interactive, as they would be able to share their fears and hopes about the pregnancy and learn together as a couple.
  • A lot of studies have been conducted regarding the efficacy of childbirth classes when it comes to pain reduction, shortening the length of labor, decreasing the amount of medication used, and the increase of enjoyment in the overall experience of childbirth.
  • It is now generally accepted that childbirth courses could increase the satisfaction and control of feelings and reduce the amount of pain felt during childbirth.

The Childbirth Plan

  • The childbirth plan consists of the choice of setting, birth attendant, birthing positions, medication options, and plans for immediate postpartum , etc.
  • Classes encourage the couple to write a birth plan and deal with these issues before the day of birth to avoid stressing out at the last minute.
  • Make sure that the couple also understands that the birth plan should be flexible in case some complications may arise.
  • Preconception classes are classes for couples who are planning to get pregnant within a short span of time.
  • These couples most likely want to learn more about what they can expect in a pregnancy and what could be their possible birth setting and procedure choices.
  • The class includes recommendation of preconception nutrition changes and physical and psychological changes that pregnancy brings.
  • Overall, preconception classes emphasize the importance of pre-pregnancy preparations to ensure a healthy fetus and mother.
  • Expectant parenting classes are for couples who are already pregnant and expecting.
  • The focus of the topics is on the family health, nutrition during pregnancy, health changes during pregnancy, and newborn care .
  • Pregnant women come to these classes accompanied by their support persons, and the class usually lasts for 4 to 8 hours over a 4 to 8-week period.
  • The classes are individualized for each group according to their special needs, such as for adolescent pregnancy, pregnant women with disabilities, or expectant adoptive parents.
  • Sibling classes are designed for older brothers and sisters to give them awareness of what would happen during birth and what they can expect a newborn would act like.
  • Simple things that a child can do during the period of pregnancy, such as eating nutritious food together with their mother and how babies grow are taught in these classes.
  • The information given during sibling classes should be appropriate to their age to make sure that the classes are effective.
  • Women who take breastfeeding classes appreciate over time the importance of breastfeeding and the advantages it gives both the mother and the baby.
  • Topics include the physiology of breastfeeding, its psychological aspects, and the advantages of exclusive breastfeeding.
  • The classes would also emphasize on ways on how a busy mother could still breastfeed her child despite a busy work schedule so the breastfeeding could continue for at least the first full year of the baby.
  • The focus of preparation for childbirth classes is mainly in the birth process.
  • The class would help the woman and her support person prepare for the childbirth experience.
  • Pain management and reduction is also a part of these classes, both with nonpharmacologic and pharmacologic measures.

Pain Management During Labor

YouTube video

  • Also known as the Partner-Coached Method, it centers on the idea that the woman’s partner should play an important role during pregnancy, labor, and childbirth until early newborn care.
  • Originated by Robert Bradley, it sheds light on the fact that pregnancy and birth are joyful natural processes.
  • The woman is taught to use an internal focus point as a disassociation technique, and she is encouraged to walk during labor.
  • This is a method proposed by Grantly Dick-Read wherein the premise is that fear leads to tension, which leads to pain.
  • The idea is for the woman to prevent the fear and break the chain between tension and pain, so she can reduce the pain of labor contractions.
  • Lack of fear is achieved through education on childbirth and relaxation , and pain management techniques.

YouTube video

  • The Lamaze Method is one of the most widely taught methods in the United States.
  • The theory is based on stimulus-response conditioning, wherein women can learn to use controlled breathing to reduce the pain of labor.
  • Formal classes are organized by Lamaze International or the International Childbirth Education Association.
  • Topics from Lamaze include prenatal nutrition and exercises, common discomforts of pregnancy, and information to prepare couples for unexpected circumstances such as cesarean birth or the need for anesthesia .
  • The gating control theory of pain is emphasized in Lamaze where the use of controlled breathing and imagery can block incoming pain sensations.
  • Lamaze classes are kept small so that there would be enough time for individualized instruction and attention to each couple.
  • The support person that the woman brings would act as her coach in labor.

The Birth Setting

One of the most important choices that a couple should also consider is the birthing center where their baby would be delivered. Choosing the place where the woman would give birth depends on the health of both the fetus and the mother, and should be in accordance with the preferences of the kind of assistance the couple would want during delivery.

Hospitals have not always been the place for birth. In earlier times, childbirth always takes place at home without any analgesia and the women give birth the natural way. However, today a lot of birthing choices were developed, and birthing centers have become hospitals instead of at home.

  • Women are still given the freedom to choose where they would want to give birth provided that the woman does not have a complicated pregnancy, and the health of the fetus is stable.
  • Women who have complicated pregnancies have less freedom in choosing that the usual because they are advised to give birth only at hospitals for provision of emergency care if needed.
  • Birthing centers are now fully equipped with resources that could compete with hospital facilities, which is why most couples consider giving birth here than going to the hospital.

Most women who give birth are always attended to by their physicians or obstetricians. But as there are more and more courses offered for family practitioners to become certified birth attendants, even with only a midwife or nurse -midwife to attend to a birth is now considered as appropriate and preferred by couples.

  • Alternative birthing centers employ more nurse-midwives to attend to births.
  • Another consideration that a woman should make is who would become her support person during labor up until her delivery.
  • In the past, experienced women in the community take up the role of the support person.
  • Later on, support persons became the father of the baby.
  • Today, any family member may take up the role of a support person.
  • Doulas are also preferred by more women today, as an addition to their support person.
  • Doulas are women who are specially prepared to assist with childbirth, and they are helpful especially when the support person would find it hard to provide enough support during labor.
  • When a woman’s support person becomes too emotional to assist the woman in labor, the doula could take in charge to allow the father or any support person to enjoy the experience and involve them emotionally in the situation.
  • The support of the doula can also reduce the rates of cesarean births, epidural anesthesia , and oxytocin augmentation, according to some research.

Hospital Birth VS Alternative Birthing Centers

Hospital birth has always been preferred by women when they want to ensure their safety during delivery and to be certain that the baby would be handled by professionals. However, the emergence of alternative birthing centers gave women the chance to choose which setting they would want to give birth in, as both could have advantages and disadvantages to consider.

  • Hospitals have standards when it comes to their maternity services as influenced by the First Consensus Initiative of the Coalition for Improving Maternity Services.
  • The organization provides a set of practices that would make a hospital mother and baby friendly.
  • The mother should be able to consider her experience as healthy and joyous regardless of her age or circumstances.
  • The mother should have access to a full range of options regarding her pregnancy, birth, and care of the newborn.
  • The mother should receive utmost support when it comes to her birthing choices based on her beliefs or culture.
  • The mother should be allowed to give birth in any environment where she would feel safe and secure.
  • The mother should receive information and updates about anything that could affect her pregnancy and her baby, with the rights to informed consent and refusal.
  • At hospitals, women are encouraged to control the discomfort and pain of labor through nonpharmacological measures despite the availability of epidural anesthesia .
  • Information is readily given to women regarding the birthing process and to help her decide on procedures that would be performed.
  • Breastfeeding is highly encouraged at hospitals to promote bonding between the mother and the baby and to aid in uterine contractions.
  • Labor, birth, and postpartum care can be done in one single room at hospitals which could provide more ease and comfort for the woman.
  • Skilled professionals attend to the woman during birth, and emergency care is readily available if the situation warrants it.
  • However, the family and the woman might be separated for one night during delivery, and the mother may sometimes feel that she is not in full control of her experience.
  • Alternative birthing centers are wellness-oriented childbirth facilities that encourage birth outside of the hospital setting while still being able to provide medical resources appropriate for any emergency that might arise.
  • Nurse-midwives attend to the birth at ABCs.
  • Before a woman is permitted to give birth at an alternative birthing center, she is screened for complications first to avoid increasing the mortality rate of mothers and infants in this setting.
  • Women are also encouraged to deal with labor pain through nonmedical measures.
  • Family members are allowed to accompany the woman throughout the experience.
  • Skilled professionals attend to the woman during birth, and emergency care is also readily available.
  • High-risk care may not be easily and immediately arranged at alternative birthing centers.
  • The stay of the woman at the facility may only be brief, so fatigue is most likely encountered after birth.
  • The woman is also expected to monitor her postpartal status independently because of her brief stay in the healthcare setting.
  • Women remain at the ABC 4 to 24 hours after birth because the woman can recover quickly because of the minimum analgesia used.

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Your First Prenatal Appointment

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INTRODUCTION

This topic will discuss the initial prenatal assessment (which may require more than one visit) in the United States. Most of these issues are common to pregnancies worldwide. Preconception care, ongoing prenatal care after the initial prenatal assessment, and issues related to patient counseling are reviewed separately.

● (See "The preconception office visit" .)

● (See "Prenatal care: Second and third trimesters" .)

● (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs" .)

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What happens during prenatal visits?

What happens during prenatal visits varies depending on how far along you are in your pregnancy.

Schedule your first prenatal visit as soon as you think you are pregnant, even if you have confirmed your pregnancy with a home pregnancy test. Early and regular prenatal visits help your health care provider monitor your health and the growth of the fetus.

The First Visit

Your first prenatal visit will probably be scheduled sometime after your eighth week of pregnancy. Most health care providers won't schedule a visit any earlier unless you have a medical condition, have had problems with a pregnancy in the past, or have symptoms such as spotting or bleeding, stomach pain, or severe nausea and vomiting. 1

You've probably heard pregnancy discussed in terms of months and trimesters (units of about 3 months). Your health care provider and health information might use weeks instead. Here's a chart that can help you understand pregnancy stages in terms of trimesters, months, and weeks.

Because your first visit will be one of your longest, allow plenty of time.

During the visit, you can expect your health care provider to do the following: 1

  • Answer your questions. This is a great time to ask questions and share any concerns you may have. Keep a running list for your visit.
  • Check your urine sample for infection and to confirm your pregnancy.
  • Check your blood pressure, weight, and height.
  • Calculate your due date based on your last menstrual cycle and ultrasound exam.
  • Ask about your health, including previous conditions, surgeries, or pregnancies.
  • Ask about your family health and genetic history.
  • Ask about your lifestyle, including whether you smoke, drink, or take drugs, and whether you exercise regularly.
  • Ask about your stress level.
  • Perform prenatal blood tests to do the following:
  • Determine your blood type and Rh (Rhesus) factor. Rh factor refers to a protein found on red blood cells. If the mother is Rh negative (lacks the protein) and the father is Rh positive (has the protein), the pregnancy requires a special level of care. 2
  • Do a blood count (e.g., hemoglobin, hematocrit).
  • Test for hepatitis B, HIV, rubella, and syphilis.
  • Do a complete physical exam, including a pelvic exam, and cultures for gonorrhea and chlamydia.
  • Do a Pap test or test for human papillomavirus (HPV) or both to screen for cervical cancer and infection with HPV, which can increase risk for cervical cancer. The timing of these tests depends on the schedule recommended by your health care provider.
  • Do an ultrasound test, depending on the week of pregnancy.
  • Offer genetic testing: screening for Down syndrome and other chromosomal problems, cystic fibrosis, other specialized testing depending on history.

Prenatal Visit Schedule

If your pregnancy is healthy, your health care provider will set up a regular schedule for visits that will probably look about like this: 1

Later Prenatal Visits

As your pregnancy progresses, your prenatal visits will vary greatly. During most visits, you can expect your health care provider to do the following:

  • Check your blood pressure.
  • Measure your weight gain.
  • Measure your abdomen to check your developing infant's growth—"fundal height" (once you begin to "show").
  • Check the fetal heart rate.
  • Check your hands and feet for swelling.
  • Feel your abdomen to find the fetus's position (later in pregnancy).
  • Do tests, such as blood tests or an ultrasound exam.

Talk to you about your questions or concerns. It's a good idea to write down your questions and bring them with you.

Several of these visits will include special tests to check for gestational diabetes (usually between 24 and 28 weeks) 3 and other conditions, depending on your age and family history.

In addition, the Centers for Disease Control and Prevention and the American Academy of Pediatrics released new vaccine guidelines for 2013 , including a recommendation for pregnant women to receive a booster of whooping cough (pertussis) vaccine. The guidelines recommend the shot be given between 27 and 36 weeks of pregnancy. 4

  • Centers for Disease Control and Prevention. (2013). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (TDAP) in pregnant women―Advisory Committee on Immunization Practices (ACIP), 2012. Retrieved September 20, 2013, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm
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A mother excited to see an ultrasound of her baby

Your first prenatal appointment: What to expect

The first prenatal visit is one of the longest appointments a woman will have during pregnancy, with several tests and a lot of important information conveyed..

During pregnancy, you need regular prenatal visits to keep yourself and the pregnancy healthy. These visits are called prenatal care appointments. In these visits, you might meet with an OB/Gyn, a midwife or a nurse practitioner.

During pregnancy, you'll meet with your prenatal care provider every four weeks until you are about 28 weeks (7 months) pregnant. After that, you'll come every two weeks. Then, in your last month of pregnancy, we'll want to see you weekly.

Your first appointment will likely be the longest of the many prenatal visits to come. At that visit, we will discuss your overall health, answer your first round of questions and help you prepare for the next nine months.

Most women make an appointment after they get a positive result from a home pregnancy test. Often, this is one or two weeks after a missed period. Call us at 505-272-2245 , and we will schedule your first prenatal appointment between six and eight weeks of pregnancy.

What to Expect

Confirming the pregnancy.

Sometimes, home pregnancy tests give false positives—it says you are pregnant, but you aren't. And unfortunately, approximately one in four pregnancies ends in miscarriage , often early in pregnancy. Before we do any other tests, we'll first confirm your pregnancy with a urine test and blood draw.

Estimating Your Due Date

We’ll also ask about your periods:

  • How old you were when they started
  • How regular they are
  • When your last period started

This information helps us estimate your due date—when we expect the baby to come. The due date is approximately nine months from the first day of your last period.

We’ll also discuss whether you want to continue with the pregnancy. Nearly half of all pregnancies in the U.S. are unplanned. It’s OK to not immediately know how you feel about being pregnant, or what you want to do. At your first prenatal visit, we  can talk you through your options . We will support you in whatever you decide.  

Personal and Family Medical History

Be prepared to discuss your personal and family medical history. This information helps us determine whether the embryo might be at risk for health problems.

Some of the topics we'll discuss include:

  • Alcohol, tobacco and caffeine use
  • Chronic conditions, such as diabetes and high blood pressure
  • Exposure to potentially toxic substances
  • Genetic disorders
  • Medications, including supplements and over-the-counter drugs
  • Past surgeries
  • Pregnancy complications
  • Travel to countries where infectious diseases—such as Zika virus or malaria—are common

At your first visit, we'll also discuss social concerns, such as whether you feel safe at home and at work. Your employer is required to give you accommodations if your job is unsafe for pregnancy. If you don’t feel safe, we can discuss options to manage that situation.

You’ll also get a battery of tests to examine the health of you and your baby. These can include blood and urine tests to look for:

  • Blood type and Rh status to determine if you are Rh negative, which can affect the pregnancy
  • Glucose levels
  • Immunity to measles and chickenpox
  • Infections such as rubella, hepatitis B and C, syphilis and HIV
  • Urinary tract infections, gonorrhea and chlamydia

Depending on your age and health history, your may also be offered an optional blood test called noninvasive prenatal testing (NIPT) . This screening can be done as early as nine weeks and can determine whether the embryo may be at risk for genetic conditions such as:

  • Down syndrome (trisomy 21)
  • Edward’s syndrome (trisomy 18)
  • Patau syndrome (trisomy 13)

Physical Exam

We’ll check your vitals such as blood pressure and calculate your body mass index to determine how much weight you should gain during pregnancy. We’ll also do a head-to-toe physical exam that may include a breast exam, pelvic exam and screenings of your heart, lungs and thyroid. If you’re due for a Pap smear to check for cervical cancer, we can also do that test at the first visit. We may also try to find out how big your uterus is and if this corresponds to how many weeks pregnant you think you are. We can usually hear fetal heart tones with a doppler after 10 weeks.

Getting an ultrasound at your first prenatal appointment is not required. But we do them more often than not. The ultrasound helps narrow down your due date and confirms that the pregnancy is in the uterus. We also may be able to hear the heartbeat at this time and see if you’re having than one baby.

However, if you’re hoping to learn whether you’re having a boy or girl, you'll have to wait a bit longer! The baby won't be that apparent on ultrasound until approximately 20 weeks.

Education and Resources

Education is a big part of prenatal care. All patients who deliver at UNM Hospital get access to:

  • Managing pregnancy symptoms: Some early pregnancy body changes are weird, but normal. These include tender, swollen breasts, fatigue or nausea and vomiting. We can discuss how to manage these symptoms and when to see your doctor.
  • Prenatal vitamins: It’s important to take prenatal vitamins with folic acid to prevent neural tube defects and walk you through some foods to avoid—such as alcohol, unpasteurized cheeses, deli meats, and raw fish. We also can suggest exercises that are safe to do during pregnancy .
  • Drug and alcohol support: During pregnancy, it's important to quit drinking, smoking and using drugs. If you need help to quit, we can recommend pregnancy-safe medications and options. For example, our Milagro Clinic is designed specifically to give pregnant patients safe, respectful addiction care.
  • Prenatal classes: From new parent classes to childbirth classes , we offer a range of in-person and Zoom classes to help you prepare for parenting.
  • Financial assistance: There are financial programs at UNM Hospital and in the community to help families with no or limited health insurance.
  • Home visits: We can connect you to programs for first time moms that offer home visits at no charge to families with new babies. At these visits, we'll answer your questions and help troubleshoot feeding concerns.

Your first prenatal appointment might seem a bit overwhelming. But we are here for you. We will give you all the information you need to have a healthy pregnancy. And we’ll be by your side, all the way.

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What to Expect at Your First Prenatal Visit

March 26, 2024

Maternal Health , OB-GYN

When you find out you’re pregnant, your to-do list instantly becomes much longer. There are people to tell, nurseries to decorate and names to consider. You also need to establish where you’ll receive your prenatal care.

Your first prenatal appointment should be scheduled seven to nine weeks after your last menstrual period.

“Early prenatal care is important because it gives your provider an opportunity to review your health history and identify risk factors we need to be proactive about,” says UNC Health certified nurse-midwife Rebeca Moretto . “It’s also an opportunity for you to ask questions about the process of pregnancy so that we address your concerns.”

Moretto and UNC Health obstetrician-gynecologist Kimberly Malloy, MD , talk about what to expect at the first prenatal visit.

Selecting Prenatal Care

“I always encourage patients to have established OB-GYN care and to have a preconception counseling appointment,” Dr. Malloy says. “We discuss your medical history and any medications you’re taking so you can prepare for a healthy pregnancy.”

You may already have a relationship with a practice that delivers babies, and your provider might know that you were preparing for pregnancy. If you don’t have a provider, Dr. Malloy recommends starting by identifying where you want to deliver .

“Patients typically choose the facility that’s closest to them, but if you have a complicated medical or obstetric history, you may want to travel farther if it means you can have access to more accommodations of care, such as a NICU [neonatal intensive care unit] or a maternal-fetal medicine department,” Dr. Malloy says.

Also, think about the people you want to be involved in your prenatal care and delivery, considering these factors:

  • You may be able to see a family medicine provider for part of your prenatal care.
  • Maybe you prefer a practice with nurse-midwives .
  • You might not be able to identify specific providers to be in the room for your delivery, as they rotate hospital shifts.
  • At an academic institution, medical students, residents and fellows could be part of your care team.

“With a team-based approach , you’ll be able to see a variety of wonderful providers, and a team ensures there are multiple eyes identifying issues,” Dr. Malloy says.

Be sure to confirm with your insurance provider that your selected healthcare practice is included in your coverage.

Preparing for Your First Prenatal Visit

Once you’ve scheduled your first appointment, there are a few things you can do to prepare and help your provider. If you are a new patient to the practice or health system, arrange to have your prior records sent to your new team or obtain copies so you can bring them to the first appointment.

“If you have a record of your most recent Pap test, or any information about prior pregnancies or complications, bring that to the appointment,” Moretto says. “If you’ve had a cesarean section , an operative report is important, especially if you want to pursue a vaginal birth after cesarean.”

Also, bring a list of any medications you take—better yet, bring the packaging or pictures of the prescription labels —so your provider can review them and make adjustments as necessary.

Start a written list of questions you have about your pregnancy, so you don’t forget to ask them when you see your provider. Talk to your family and your partner’s family about hereditary medical issues that could affect your baby so that you can share those details with your doctor.

While you’re waiting for your initial appointment date, know that you can reach out to your care team with questions or concerns.

“Vaginal bleeding and spotting are common in early pregnancy,” Dr. Malloy says. “If it’s a persistent problem, call the provider so they can assess whether you need to be seen sooner.”

Testing at the First Prenatal Visit

The first prenatal visit probably will be the longest of your pregnancy. It will include a complete physical exam, including pelvic and breast exams. Your blood pressure and weight will be recorded at this and future visits.

A urine sample will be taken so that your provider can check for signs of infection and dehydration and levels of protein and glucose.

You’ll also have your blood drawn for a variety of labs, including anemia, immunity to certain infections, blood type and Rh factor .

At this appointment you might have your first ultrasound, depending on the practice. Some providers schedule the first one beforehand so that the images can be reviewed at this visit. You may also be able to see or hear fetal heart tones.

All of this testing helps your provider identify and monitor potential risk factors and issues that could arise during pregnancy, such as hypertension, diabetes and preeclampsia .

In addition to this testing, you’ll have a consultation with your provider, who will review your entire health history, including medications, surgeries and prior pregnancies. If you have concerns about genetic issues, your provider can identify additional screenings or tests you might wish to pursue.

The care team will also give you guidance on how to make your pregnancy as healthy as possible and to prepare for the rest of pregnancy , childbirth and lactation .

“We’ll go over nutrition issues , such as anticipated weight gain and additional caloric intake,” Dr. Malloy says. “We’ll review vaccines that may be necessary during pregnancy, make recommendations for any medications you may need and discuss precautions you may need to take.”

Moretto adds, “It’s also a time to talk about mental health resources. Pregnancy is impactful on mental health , so we can help make connections for therapy and other relevant resources if needed.”

Your due date will be set at your first prenatal visit, but you won’t find out the sex until the second trimester. Finally, your provider will review the schedule for the rest of your prenatal care, dependent on your individual needs and risks.

If you’re pregnant or thinking about becoming pregnant, you should talk to your doctor. Need a doctor? Find one near you .

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Please call 911 or go to the nearest emergency room if you are experiencing a medical emergency.

Prenatal care and tests

first nurse visit pregnancy

Medical checkups and screening tests help keep you and your baby healthy during pregnancy. This is called prenatal care. It also involves education and counseling about how to handle different aspects of your pregnancy. During your visits, your doctor may discuss many issues, such as healthy eating and physical activity, screening tests you might need, and what to expect during labor and delivery.

Choosing a prenatal care provider

You will see your prenatal care provider many times before you have your baby. So you want to be sure that the person you choose has a good reputation, and listens to and respects you. You will want to find out if the doctor or midwife can deliver your baby in the place you want to give birth , such as a specific hospital or birthing center. Your provider also should be willing and able to give you the information and support you need to make an informed choice about whether to breastfeed or bottle-feed.

Health care providers that care for women during pregnancy include:

  • Obstetricians (OB) are medical doctors who specialize in the care of pregnant women and in delivering babies. OBs also have special training in surgery so they are also able to do a cesarean delivery . Women who have health problems or are at risk for pregnancy complications should see an obstetrician. Women with the highest risk pregnancies might need special care from a maternal-fetal medicine specialist .
  • Family practice doctors are medical doctors who provide care for the whole family through all stages of life. This includes care during pregnancy and delivery, and following birth. Most family practice doctors cannot perform cesarean deliveries.
  • A certified nurse-midwife (CNM) and certified professional midwife (CPM) are trained to provide pregnancy and postpartum care. Midwives can be a good option for healthy women at low risk for problems during pregnancy, labor, or delivery. A CNM is educated in both nursing and midwifery. Most CNMs practice in hospitals and birth centers. A CPM is required to have experience delivering babies in home settings because most CPMs practice in homes and birthing centers. All midwives should have a back-up plan with an obstetrician in case of a problem or emergency.

Ask your primary care doctor, friends, and family members for provider recommendations. When making your choice, think about:

  • Personality and bedside manner
  • The provider's gender and age
  • Office location and hours
  • Whether you always will be seen by the same provider during office checkups and delivery
  • Who covers for the provider when she or he is not available
  • Where you want to deliver
  • How the provider handles phone consultations and after-hour calls

What is a doula?

A doula (DOO-luh) is a professional labor coach, who gives physical and emotional support to women during labor and delivery. They offer advice on breathing, relaxation, movement, and positioning. Doulas also give emotional support and comfort to women and their partners during labor and birth. Doulas and midwives often work together during a woman's labor. A recent study showed that continuous doula support during labor was linked to shorter labors and much lower use of:

  • Pain medicines
  • Oxytocin (ok-see-TOHS-uhn) (medicine to help labor progress)
  • Cesarean delivery

Check with your health insurance company to find out if they will cover the cost of a doula. When choosing a doula, find out if she is certified by Doulas of North America (DONA) or another professional group.

Places to deliver your baby

Many women have strong views about where and how they'd like to deliver their babies. In general, women can choose to deliver at a hospital, birth center, or at home. You will need to contact your health insurance provider to find out what options are available. Also, find out if the doctor or midwife you are considering can deliver your baby in the place you want to give birth.

Hospitals are a good choice for women with health problems, pregnancy complications, or those who are at risk for problems during labor and delivery. Hospitals offer the most advanced medical equipment and highly trained doctors for pregnant women and their babies. In a hospital, doctors can do a cesarean delivery if you or your baby is in danger during labor. Women can get epidurals or many other pain relief options. Also, more and more hospitals now offer on-site birth centers, which aim to offer a style of care similar to standalone birth centers.

Questions to ask when choosing a hospital:

  • Is it close to your home?
  • Is a doctor who can give pain relief, such as an epidural, at the hospital 24-hours a day?
  • Do you like the feel of the labor and delivery rooms?
  • Are private rooms available?
  • How many support people can you invite into the room with you?
  • Does it have a neonatal intensive care unit (NICU) in case of serious problems with the baby?
  • Can the baby stay in the room with you?
  • Does the hospital have the staff and set-up to support successful breastfeeding?
  • Does it have an on-site birth center?

Birth or birthing centers give women a "homey" environment in which to labor and give birth. They try to make labor and delivery a natural and personal process by doing away with most high-tech equipment and routine procedures. So, you will not automatically be hooked up to an IV. Likewise, you won't have an electronic fetal monitor around your belly the whole time. Instead, the midwife or nurse will check in on your baby from time to time with a handheld machine. Once the baby is born, all exams and care will occur in your room. Usually certified nurse-midwives, not obstetricians, deliver babies at birth centers. Healthy women who are at low risk for problems during pregnancy, labor, and delivery may choose to deliver at a birth center.

Women can not receive epidurals at a birth center, although some pain medicines may be available. If a cesarean delivery becomes necessary, women must be moved to a hospital for the procedure. After delivery, babies with problems can receive basic emergency care while being moved to a hospital.

Many birthing centers have showers or tubs in their rooms for laboring women. They also tend to have comforts of home like large beds and rocking chairs. In general, birth centers allow more people in the delivery room than do hospitals.

Birth centers can be inside of hospitals, a part of a hospital or completely separate facilities. If you want to deliver at a birth center, make sure it meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers. Accredited birth centers must have doctors who can work at a nearby hospital in case of problems with the mom or baby. Also, make sure the birth center has the staff and set-up to support successful breastfeeding.

Homebirth is an option for healthy pregnant women with no risk factors for complications during pregnancy, labor or delivery. It is also important women have a strong after-care support system at home. Some certified nurse midwives and doctors will deliver babies at home. Many health insurance companies do not cover the cost of care for homebirths. So check with your plan if you'd like to deliver at home.

Homebirths are common in many countries in Europe. But in the United States, planned homebirths are not supported by the American Congress of Obstetricians and Gynecologists (ACOG). ACOG states that hospitals are the safest place to deliver a baby. In case of an emergency, says ACOG, a hospital's equipment and highly trained doctors can provide the best care for a woman and her baby.

If you are thinking about a homebirth, you need to weigh the pros and cons. The main advantage is that you will be able to experience labor and delivery in the privacy and comfort of your own home. Since there will be no routine medical procedures, you will have control of your experience.

The main disadvantage of a homebirth is that in case of a problem, you and the baby will not have immediate hospital/medical care. It will have to wait until you are transferred to the hospital. Plus, women who deliver at home have no options for pain relief.

To ensure your safety and that of your baby, you must have a highly trained and experienced midwife along with a fail-safe back-up plan. You will need fast, reliable transportation to a hospital. If you live far away from a hospital, homebirth may not be the best choice. Your midwife must be experienced and have the necessary skills and supplies to start emergency care for you and your baby if need be. Your midwife should also have access to a doctor 24 hours a day.

Prenatal checkups

During pregnancy, regular checkups are very important. This consistent care can help keep you and your baby healthy, spot problems if they occur, and prevent problems during delivery. Typically, routine checkups occur:

  • Once each month for weeks four through 28
  • Twice a month for weeks 28 through 36
  • Weekly for weeks 36 to birth

Women with high-risk pregnancies need to see their doctors more often.

At your first visit your doctor will perform a full physical exam, take your blood for lab tests, and calculate your due date. Your doctor might also do a breast exam, a pelvic exam to check your uterus (womb), and a cervical exam, including a Pap test. During this first visit, your doctor will ask you lots of questions about your lifestyle, relationships, and health habits. It's important to be honest with your doctor.

After the first visit, most prenatal visits will include:

  • Checking your blood pressure and weight
  • Checking the baby's heart rate
  • Measuring your abdomen to check your baby's growth

You also will have some routine tests throughout your pregnancy, such as tests to look for anemia , tests to measure risk of gestational diabetes , and tests to look for harmful infections.

Become a partner with your doctor to manage your care. Keep all of your appointments — every one is important! Ask questions and read to educate yourself about this exciting time.

Monitor your baby's activity

After 28 weeks, keep track of your baby's movement. This will help you to notice if your baby is moving less than normal, which could be a sign that your baby is in distress and needs a doctor's care. An easy way to do this is the "count-to-10" approach. Count your baby's movements in the evening — the time of day when the fetus tends to be most active. Lie down if you have trouble feeling your baby move. Most women count 10 movements within about 20 minutes. But it is rare for a woman to count less than 10 movements within two hours at times when the baby is active. Count your baby's movements every day so you know what is normal for you. Call your doctor if you count less than 10 movements within two hours or if you notice your baby is moving less than normal. If your baby is not moving at all, call your doctor right away.

Prenatal tests

Tests are used during pregnancy to check your and your baby's health. At your fist prenatal visit, your doctor will use tests to check for a number of things, such as:

  • Your blood type and Rh factor
  • Infections, such as toxoplasmosis and sexually transmitted infections (STIs), including hepatitis B , syphilis , chlamydia , and HIV
  • Signs that you are immune to rubella (German measles) and chicken pox

Throughout your pregnancy, your doctor or midwife may suggest a number of other tests, too. Some tests are suggested for all women, such as screenings for gestational diabetes, Down syndrome, and HIV. Other tests might be offered based on your:

  • Personal or family health history
  • Ethnic background
  • Results of routine tests

Some tests are screening tests. They detect risks for or signs of possible health problems in you or your baby. Based on screening test results, your doctor might suggest diagnostic tests. Diagnostic tests confirm or rule out health problems in you or your baby.

Understanding prenatal tests and test results

If your doctor suggests certain prenatal tests, don't be afraid to ask lots of questions. Learning about the test, why your doctor is suggesting it for you, and what the test results could mean can help you cope with any worries or fears you might have. Keep in mind that screening tests do not diagnose problems. They evaluate risk. So if a screening test comes back abnormal, this doesn't mean there is a problem with your baby. More information is needed. Your doctor can explain what test results mean and possible next steps.

Avoid keepsake ultrasounds

You might think a keepsake ultrasound is a must-have for your scrapbook. But, doctors advise against ultrasound when there is no medical need to do so. Some companies sell "keepsake" ultrasound videos and images. Although ultrasound is considered safe for medical purposes, exposure to ultrasound energy for a keepsake video or image may put a mother and her unborn baby at risk. Don't take that chance.

High-risk pregnancy

Pregnancies with a greater chance of complications are called "high-risk." But this doesn't mean there will be problems. The following factors may increase the risk of problems during pregnancy:

  • Very young age or older than 35
  • Overweight or underweight
  • Problems in previous pregnancy
  • Health conditions you have before you become pregnant, such as high blood pressure , diabetes , autoimmune disorders , cancer , and HIV
  • Pregnancy with twins or other multiples

Health problems also may develop during a pregnancy that make it high-risk, such as gestational diabetes or preeclampsia . See Pregnancy complications to learn more.

Women with high-risk pregnancies need prenatal care more often and sometimes from a specially trained doctor. A maternal-fetal medicine specialist is a medical doctor that cares for high-risk pregnancies.

If your pregnancy is considered high risk, you might worry about your unborn baby's health and have trouble enjoying your pregnancy. Share your concerns with your doctor. Your doctor can explain your risks and the chances of a real problem. Also, be sure to follow your doctor's advice. For example, if your doctor tells you to take it easy, then ask your partner, family members, and friends to help you out in the months ahead. You will feel better knowing that you are doing all you can to care for your unborn baby.

Paying for prenatal care

Pregnancy can be stressful if you are worried about affording health care for you and your unborn baby. For many women, the extra expenses of prenatal care and preparing for the new baby are overwhelming. The good news is that women in every state can get help to pay for medical care during their pregnancies. Every state in the United States has a program to help. Programs give medical care, information, advice, and other services important for a healthy pregnancy.

Learn more about programs available in your state.

You may also find help through these places:

  • Local hospital or social service agencies – Ask to speak with a social worker on staff. She or he will be able to tell you where to go for help.
  • Community clinics – Some areas have free clinics or clinics that provide free care to women in need.
  • Women, Infants and Children (WIC) Program – This government program is available in every state. It provides help with food, nutritional counseling, and access to health services for women, infants, and children.
  • Places of worship

More information on prenatal care and tests

Read more from womenshealth.gov.

  • Pregnancy and Medicines Fact Sheet - This fact sheet provides information on the safety of using medicines while pregnant.

Explore other publications and websites

  • Chorionic Villus Sampling (CVS) (Copyright © March of Dimes) - Chorionic villus sampling (CVS) is a prenatal test that can diagnose or rule out certain birth defects. The test is generally performed between 10 and 12 weeks after a woman's last menstrual period. This fact sheet provides information about this test, and how the test sample is taken.
  • Folic Acid (Copyright © March of Dimes) - This fact sheet stresses the importance of getting higher amounts of folic acid during pregnancy in order to prevent neural tube defects in unborn children.
  • Folic Acid: Questions and Answers - The purpose of this question and answer sheet is to educate women of childbearing age on the importance of consuming folic acid every day to reduce the risk of spina bifida.
  • For Women With Diabetes: Your Guide to Pregnancy - This booklet discusses pregnancy in women with diabetes. If you have type 1 or type 2 diabetes and you are pregnant or hoping to get pregnant soon, you can learn what to do to have a healthy baby. You can also learn how to take care of yourself and your diabetes before, during, and after your pregnancy.
  • Genetics Home Reference - This website provides information on specific genetic conditions and the genes or chromosomes responsible for these conditions.
  • Guidelines for Vaccinating Pregnant Women - This publication provides information on routine and other vaccines and whether they are recommended for use during pregnancy.
  • How Your Baby Grows (Copyright © March of Dimes) - This site provides information on the development of your baby and the changes in your body during each month of pregnancy. In addition, for each month, it provides information on when to go for prenatal care appointments and general tips to take care of yourself and your baby.
  • Pregnancy Registries - Pregnancy registries help women make informed and educated decisions about using medicines during pregnancy. If you are pregnant and currently taking medicine — or have been exposed to a medicine during your pregnancy — you may be able to participate and help in the collection of this information. This website provides a list of pregnancy registries that are enrolling pregnant women.
  • Pregnancy, Breastfeeding, and Bone Health - This publication provides information on pregnancy-associated osteoporosis, lactation and bone loss, and what you can do to keep your bones healthy during pregnancy.
  • Prenatal Care: First-Trimester Visits (Copyright © Mayo Foundation) - This fact sheet explains what to expect during routine exams with your doctor. In addition, if you have a condition that makes your pregnancy high-risk, special tests may be performed on a regular basis to check the baby's health.
  • Ten Tips for a Healthy Pregnancy (Copyright © Lamaze International) - This easy-to-read fact sheet provides 10 simple recommendations to help mothers have a healthy pregnancy.
  • Ultrasound (Copyright © March of Dimes) - This fact sheet discusses the use of an ultrasound in prenatal care at each trimester.

Connect with other organizations

  • American Academy of Family Physicians
  • American Association of Birth Centers
  • American College of Obstetricians and Gynecologists
  • Center for Research on Reproduction and Women's Health, University of Pennsylvania Medical Center
  • Dona International
  • March of Dimes
  • Maternal and Child Health Bureau, HRSA, HHS
  • National Association for Down Syndrome
  • National Center on Birth Defects and Developmental Disabilities, CDC
  • Public Information and Communications Branch, NICHD, NIH, HHS
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Prenatal care in your first trimester

Trimester means "3 months." A normal pregnancy lasts around 10 months and has 3 trimesters.

The word prenatal means before birth. The first trimester starts when your baby is conceived. It continues through week 14 of your pregnancy. Your health care provider may talk about your pregnancy in weeks, rather than in months or trimesters.

Your First Prenatal Visit

You should schedule your first prenatal visit soon after you learn that you are pregnant. Your doctor or midwife will:

  • Draw your blood
  • Perform a full pelvic exam
  • Do a Pap smear and cultures to look for infections or problems

Your doctor or midwife will listen for your baby's heartbeat, but may not be able to hear it. Most often, the heartbeat cannot be heard or seen on ultrasound until at least 6 to 7 weeks.

During this first visit, your doctor or midwife will ask you questions about:

  • Your overall health
  • Any health problems you have
  • Past pregnancies
  • Medicines, herbs, or vitamins you take
  • Whether or not you exercise
  • Whether you smoke, use tobacco, drink alcohol or take drugs
  • Whether you or your partner have genetic disorders or health problems that run in your family

You will have many visits to talk about a birthing plan. You can also discuss it with your doctor or midwife at your first visit.

The first visit will also be a good time to talk about:

  • Eating healthy , exercising, getting adequate sleep, and making lifestyle changes while you are pregnant
  • Common symptoms during pregnancy such as fatigue, heartburn, and varicose veins
  • How to manage morning sickness
  • What to do about vaginal bleeding during early pregnancy
  • What to expect at each visit

You will also be given prenatal vitamins with iron if you are not already taking them.

Follow-up Prenatal Visits

In your first trimester, you will have a prenatal visit every month. The visits may be quick, but they are still important. It is OK to bring your partner or labor coach with you.

During your visits, your doctor or midwife will:

  • Check your blood pressure.
  • Check for fetal heart sounds.
  • Take a urine sample to test for sugar or protein in your urine. If either of these is found, it could mean that you have gestational diabetes or high blood pressure caused by pregnancy.

At the end of each visit, your doctor or midwife will tell you what changes to expect before your next visit. Tell your doctor if you have any problems or concerns. It is OK to talk about them even if you do not feel that they are important or related to your pregnancy.

At your first visit, your doctor or midwife will draw blood for a group of tests known as the prenatal panel. These tests are done to find problems or infections early in the pregnancy.

This panel of tests includes, but is not limited to:

  • A complete blood count (CBC)
  • Blood typing (including Rh screen)
  • Rubella viral antigen screen (this shows how immune you are to the disease Rubella)
  • Hepatitis panel (this shows if you are positive for hepatitis A, B, or C)
  • Syphilis test
  • HIV test (this test shows if you are positive for the virus that causes AIDS)
  • Cystic fibrosis screen (this test shows if you are a carrier for cystic fibrosis)
  • A urine analysis and culture

Ultrasounds

An ultrasound is a simple, painless procedure. A wand that uses sound waves will be placed on your belly. The sound waves will let your doctor or midwife see the baby.

You should have an ultrasound done in the first trimester to get an idea of your due date. The first trimester ultrasound will usually be a vaginal ultrasound.

Genetic Testing

All women are offered genetic testing to screen for birth defects and genetic problems, such as Down syndrome or brain and spinal column defects.

  • If your doctor thinks that you need any of these tests, talk about which ones will be best for you.
  • Be sure to ask what the results could mean for you and your baby.
  • A genetic counselor can help you understand your risks and test results.
  • There are many options now for genetic testing. Some of these tests carry some risks to your baby, while others do not.

Women who may be at higher risk for these genetic problems include:

  • Women who have had a fetus with genetic problems in earlier pregnancies
  • Women, age 35 years or older
  • Women with a strong family history of inherited birth defects

In one test, your provider can use an ultrasound to measure the back of the baby's neck. This is called nuchal translucency .

  • A blood test is also done.
  • Together, these 2 measures will tell if the baby is at risk for having Down syndrome.
  • If a test called a quadruple screen is done in the second trimester, the results of both tests are more accurate than doing either test alone. This is called integrated screening. If the test is positive, an amniocentesis or cell-free DNA test may be recommended.

Another test, called chorionic villus sampling (CVS) , can detect Down syndrome and other genetic disorders as early as 10 weeks into a pregnancy.

A newer test, called cell free DNA testing, looks for small pieces of your baby's genes in a sample of blood from the mother. This test is newer, but offers a lot of promise for accuracy without risks of miscarriage. It may reduce the need for an amniocentesis, and so is safer for the baby.

There are other tests that may be done in the second trimester .

When to Call the Doctor

Contact your provider if:

  • You have a significant amount of nausea and vomiting.
  • You have bleeding or cramping.
  • You have increased discharge or a discharge with odor.
  • You have a fever, chills, or pain when passing urine.
  • You have any questions or concerns about your health or your pregnancy.

Alternative Names

Pregnancy care - first trimester

Gregory KD, Ramos DE, Jauniaux ERM. Preconception and prenatal care. In:.Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 7th ed. Philadelphia, PA: Elsevier; 2021:chap 5.

Hobel CJ, Williams J. Antepartum care. In: Hacker N, Gambone JC, Hobel CJ, eds. Hacker & Moore's Essentials of Obstetrics and Gynecology . 6th ed. Philadelphia, PA: Elsevier; 2016:chap 7.

Magowan BA, Owen P, Thomson A. Antenatal and postnatal care. In: Magowan BA, Owen P, Thomson A, eds. Clinical Obstetrics and Gynaecology . 4th ed. Philadelphia, PA: Elsevier; 2019:chap 22.

Symonds I. Early pregnancy care. In: Symonds I, Arulkumaran S, eds. Essential Obstetrics and Gynaecology . 6th ed. Philadelphia, PA: Elsevier; 2020:chap 18.

Williams DE, Pridjian G. Obstetrics. In: Rakel RE, Rakel DP, eds. Textbook of Family Medicine . 9th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 20.

Review Date 4/19/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Related MedlinePlus Health Topics

  • Prenatal Care

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SARAH INÉS RAMÍREZ, MD, FAAFP

Am Fam Physician. 2023;108(2):139-150

Related AFP Community Blog:   Practice Ancestry-Based Medicine, not Racial Essentialism

Related editorial:   Perinatal Care of Transgender Patients, Adolescent Patients, and Patients With Opioid Use Disorder

Author disclosure: No relevant financial relationships.

Well-coordinated prenatal care that follows an evidence-based, informed process results in fewer hospital admissions, improved education, greater satisfaction, and lower pregnancy-associated morbidity and mortality. Care initiated at 10 weeks or earlier improves outcomes. Identification and treatment of periodontal disease decreases preterm delivery risk. A prepregnancy body mass index greater than 25 kg per m 2 is associated with gestational diabetes mellitus, hypertension, miscarriage, and stillbirth. Advanced maternal and paternal age (35 years or older) is associated with gestational diabetes, hypertension, miscarriage, intrauterine growth restriction, aneuploidy, birth defects, and stillbirth. Rh o (D) immune globulin decreases alloimmunization risk in a patient who is RhD-negative carrying a fetus who is RhD-positive. Treatment of iron deficiency anemia decreases the risk of preterm delivery, intrauterine growth restriction, and perinatal depression. Ancestry-based genetic risk stratification using family history can inform genetic screening. Folic acid supplementation (400 to 800 mcg daily) decreases the risk of neural tube defects. All pregnant patients should be screened for asymptomatic bacteriuria, sexually transmitted infections, and immunity against rubella and varicella and should receive tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), influenza, and COVID-19 vaccines. Testing for group B Streptococcus should be performed between 36 and 37 weeks, and intrapartum antibiotic prophylaxis should be initiated to decrease the risk of neonatal infection. Because of the impact of social determinants of health on outcomes, universal screening for depression, anxiety, intimate partner violence, substance use, and food insecurity is recommended early in pregnancy. Screening for gestational diabetes between 24 and 28 weeks is recommended for all patients. People at risk of preeclampsia, including those diagnosed with COVID-19 in pregnancy, should be offered 81 mg of aspirin daily starting at 12 weeks. Chronic hypertension should be treated to a blood pressure of less than 140/90 mm Hg.

Family physicians provide family-centered care for individuals and families before, during, and after the birth of a child. Well-coordinated prenatal care that follows an evidence-based, informed process results in fewer hospital admissions, improved education, greater care satisfaction, improved perinatal outcomes, and mitigates pregnancy-associated morbidity and mortality. 1 Family physicians are uniquely positioned to address social determinants of health while ensuring quality of care.

Prenatal Care Visits

Initiation of care between six and 10 weeks allows for identification of preexisting conditions that negatively affect maternal-fetal outcomes (e.g., diabetes mellitus, hypertension, obesity) 2 ; however, 22% of pregnant patients do not receive care during this time. 2 The COVID-19 pandemic resulted in a reevaluation of the number of physician visits needed, with an emphasis on increased flexibility, allowing for a combination of virtual and in-person visits depending on risk. 3 Table 1 outlines the components of prenatal care. 1 , 4 – 22 Table 2 provides opportunities for educating pregnant patients during prenatal care visits. 6 , 8 , 14 – 19 , 23 – 29

PHYSICAL EXAMINATION

Weight, height, and blood pressure should be measured at the first prenatal visit. Early identification of periodontal disease and treatment decreases adverse pregnancy outcomes. 7 Treatment may be performed in the second trimester, and emergent treatment may be completed at any time during pregnancy. 7 A bimanual pelvic examination has poor predictive value for clinical pelvimetry and screening for disease (i.e., sexually transmitted infections and cancer) but may be used as a diagnostic aid in patients with a discrepancy between uterine size and gestational age, which warrants ultrasonography assessment. 30 A pelvic examination is also useful in a symptomatic patient for evaluating spontaneous labor (e.g., cervical dilation, rupture of amniotic membranes). The clinical breast examination is a diagnostic aid in the symptomatic patient and addresses breastfeeding concerns or barriers but does not demonstrate benefit in patients already receiving screening mammograms and does not decrease mortality. 31 – 33

MATERNAL WEIGHT GAIN AND NUTRITION

A prepregnancy body mass index (BMI) greater than 25 kg per m 2 is associated with preterm delivery, gestational diabetes, gestational hypertension, and preeclampsia. A BMI greater than 30 kg per m 2 is also associated with an increased risk of miscarriage, stillbirth, and obstructive sleep apnea. 6 Prepregnancy BMI informs the timing of fetal surveillance, nutritional counseling, and goals for gestational weight gain. Table 3 lists general dietary guidelines for pregnant people. 8 , 17 , 34 , 35 For Black and Hispanic people, a prepregnancy BMI greater than 25 kg per m 2 and the associated poor outcomes are worse compared with non-Hispanic White people. 36

PARENTAL AGE AT CONCEPTION

Advanced maternal and paternal age (35 years and older) is associated with poor outcomes (i.e., aneuploidy, birth defects, gestational diabetes, hypertension, intrauterine growth restriction [IUGR], miscarriage, and stillbirth). Activities focused on improving perinatal outcomes for this group, such as a detailed fetal anatomic screening on ultrasonography, may decrease morbidity and mortality. 37

PREGNANCY DATING AND ULTRASONOGRAPHY

Accurate gestational age estimation is critical to quality care because it enables more precise timing of interventions (e.g., aspirin for preeclampsia prevention, steroids for fetal lung maturity), screening tests, and delivery. Up to 40% of people estimate their last menstrual period incorrectly; therefore, ultrasonography is recommended if uncertainty exists and for patients with irregular menstrual cycles, irregular bleeding, and discrepancy between uterine size and gestational age. 1 , 38 Ultrasonography before 24 weeks decreases missed multiple gestations and post-term inductions. 39 Although routine third-trimester ultrasonography may increase detection of IUGR, it does not improve outcomes. 40 If malpresentation is suspected on physical examination, confirmation with ultrasonography is recommended. 4

ALLOIMMUNIZATION

For patients who are RhD-negative and carrying a fetus who is RhD-positive, the alloimmunization risk is 1.5% to 2% in the setting of spontaneous abortion and 4% to 5% with dilation and curettage. The risk is decreased by 80% to 90% with anti-D immune globulin. 41 Testing for the ABO blood group and RhD antibodies should be performed early in pregnancy. A 300-mcg dose of anti-D immune globulin is recommended for RhD-negative pregnant patients at 28 weeks and again within 72 hours of delivery if the infant is RhD-positive. 41

Iron deficiency anemia increases the risk of preterm delivery, IUGR, and perinatal depression. The U.S. Preventive Services Task Force found insufficient evidence to assess the benefits and harms of screening for anemia in pregnancy. 42 Screening is recommended by the American College of Obstetricians and Gynecologists early in pregnancy, with iron treatment if deficient. 43 Intravenous iron should be considered for patients who cannot tolerate oral iron or in whom oral iron has been ineffective at correcting the deficiency. 43 Patients with non–iron deficiency anemia, or if iron repletion is ineffective within six weeks, should be referred to a hematologist for further evaluation. Iron supplementation in the first trimester decreases the prevalence of iron deficiency. 43

INHERITED CONDITIONS

Pregnant patients should be counseled and offered aneuploidy (extra or missing chromosomes) screening in early pregnancy, regardless of age. 44 In the United States, 1 in 150 infants has a chromosomal condition, the most common being trisomy 21 (Down syndrome). 44 Table 4 compares screening tests for Down syndrome. 1 , 45 , 46 If a screening test is positive, amniocentesis at 15 weeks or more or chorionic villous sampling between 11 and 13 weeks is recommended. Both procedures have similar rates of fetal loss. 47 At 35 years of age, the risk of Down syndrome (1 in 294 births) is similar to that of fetal loss from amniocentesis. 47 Serum and nuchal translucency testing can screen for other trisomies, including 13 and 18, the protocols for which have lower sensitivities and higher specificities compared with screening protocols for trisomy 21 because they are rarer. 47

Additional genetic screening should be based on maternal and paternal personal and family histories. Race is a social construct, necessitating a shift in genetic risk stratification from race-based to ancestry-based. Sickle cell disease affects up to 100,000 people in the United States, but its inheritance pattern (1:10) is based on people with African ancestry, which includes much of the world. 48 Cystic fibrosis is inherited mainly by people of European ancestry (1:25), but ignoring the possibility of European ancestry in certain racial and ethnic groups results in an underestimation of its prevalence: African (1:61), Hispanic (1:40), and Mediterranean (1:29). 49

NEURAL TUBE DEFECTS

In the United States, neural tube defects affect approximately 2,600 infants per year, with the highest prevalence in Hispanic populations. 35 , 50 All pregnant patients should be counseled and offered screening with maternal serum alpha fetoprotein. 35 Folic acid, 400 to 800 mcg daily, started at least one month before conception and continued until the end of the first trimester, decreases the incidence of neural tube defects by nearly 78%. 35 Patients taking folic acid antagonists (e.g., carbamazepine, methotrexate, trimethoprim) or who have a history of carrying a fetus with a neural tube defect should take 4 mg of folic acid daily, starting at least three months before conception. 35

THYROID DISORDERS

There is no evidence that screening for thyroid disorders improves pregnancy outcomes. Thyroid-stimulating hormone levels should be measured if there is a history of thyroid disease or symptoms of disease. If the level is abnormal, a free thyroxine test helps determine the etiology. 51 Hypothyroidism complicates 1 to 3 per 1,000 pregnancies and increases the risk of fetal loss, preeclampsia, IUGR, and stillbirth. Hyperthyroidism occurs in 2 per 1,000 pregnancies and is associated with miscarriage, preeclampsia, IUGR, preterm delivery, thyroid storm, and congestive heart failure. 51 The effect of subclinical hypothyroidism on a child's neurocognitive development is not well understood, and the effectiveness of treatment with levothyroxine is unproven. 51

CERVICAL CANCER

Intervals for cervical cancer screening are based on patient age, cytology history, and history of the presence of high-risk human papillomavirus (HPV). Routine screening for people at average risk of cervical cancer should begin at 21 years of age. Screening can be performed with either cytology alone every three years, HPV screening alone every five years, or cytology plus HPV screening every five years starting at 25 years of age. Screening is not indicated for people 65 years and older with negative screening in the previous 10 years, and no history of cervical intraepithelial neoplasia grade 2 or higher in the past 25 years. 52 Colposcopy is indicated when the risk of cervical intraepithelial neoplasia grade 3 is greater than 4%. Surveillance of high-grade lesions should be performed every 12 to 24 weeks. 52 , 53 Although colposcopy and cervical biopsy can be safely performed during pregnancy, endocervical sampling should be deferred until postpartum. 53

Infectious Disease

Bacteriuria.

Asymptomatic bacteriuria complicates up to 15% of pregnancies in the United States, 30% of which progress to pyelonephritis if untreated. 54 All pregnant patients should be screened for bacteriuria at the first prenatal visit. 54 A culture from a midstream or clean-catch sample with greater than 100,000 colony-forming units per mL of a single pathogen is considered positive and treated to decrease the risk of pyelonephritis and subsequent preterm delivery. 54

SEXUALLY TRANSMITTED INFECTIONS

Sexually transmitted infections can affect prenatal outcomes. 55 – 57 Table 5 lists routine screening and treatment for sexually transmitted infections in pregnancy. 55 , 56

Rubella immunity screening during the first prenatal visit is recommended. Postpartum vaccination should also be offered if the patient is not immune to prevent congenital rubella syndrome in subsequent pregnancies. 1 , 58 The presence of rubella immunoglobulin G should be interpreted with caution in patients recently migrating from areas where rubella is endemic because this may indicate a recent infection. 58 Rubella is a live vaccine and should not be administered during pregnancy but is safe during lactation after delivery. 59 , 60

Maternal varicella can result in congenital varicella syndrome (i.e., IUGR and limb, ophthalmologic, and neurologic abnormalities) and neonatal varicella; infection can occur from approximately five days before to two days after birth. A negative history of varicella infection or vaccination warrants serologic testing, and if immunoglobulin G is negative, varicella exposure should be avoided. Postpartum vaccination should be offered. 61

Although tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination is recommended for anyone in close contact with the infant, only antenatal maternal vaccination ensures increased protection against neonatal pertussis. 62 Pregnant patients should receive a Tdap vaccine beginning at 27 weeks to maximize time for passive immunity to the fetus through the placental transfer of maternal antibodies; vaccination is recommended in each subsequent pregnancy. 62

INFLUENZA AND COVID-19

Influenza and COVID-19 infection in pregnancy increase the risk of intensive care unit admission, preterm delivery, stillbirth, and maternal death. 63 , 64 COVID-19 infection almost doubles the risk of developing preeclampsia 64 ; therefore, initiating low-dose aspirin (81 mg daily) starting at 12 weeks should be considered. 5 Pregnant patients and their household contacts should be vaccinated for influenza and COVID-19. 63 , 64

GROUP B STREPTOCOCCUS

In the United States, group B Streptococcus (GBS) is the leading cause of infection in the first three months of life; 25% of all pregnant patients are GBS carriers. 65 , 66 Screening with a vaginal-rectal swab for culture between 36 and 37 weeks is recommended. 67 Intrapartum antibiotic prophylaxis decreases neonatal mortality. Antibiotics are recommended when there is GBS bacteriuria with the current pregnancy, a history of a previous infant affected by GBS (e.g., septicemia, meningitis, pneumonia, death), or unknown GBS status and risk factors (e.g., preterm labor, rupture of membranes more than 18 hours before delivery, GBS in previous pregnancy). 67 Patients with GBS bacteriuria in the current pregnancy are assumed to be colonized and do not need subsequent screening. 67

Social Determinants of Health

Social determinants of health represent up to 80% of the factors that directly affect a person's health. 68 Physicians who provide prenatal care play a critical role in mitigating the burden that social determinants of health play on maternal-child health without compromising the quality of care delivered. 69 An increased burden from social determinants of health increases the risk of depression, anxiety, intimate partner violence, substance use, and food insecurity 70 , 71 ; therefore, universal screening is recommended early in pregnancy.

DEPRESSION AND ANXIETY-RELATED DISORDERS

After the COVID-19 pandemic, rates of perinatal depression and anxiety have increased. People who are non-White, 24 years or younger, or who have 12 years or less of education, lower socioeconomic status, or a history of intimate partner violence or sexual trauma are at higher risk. 11 , 72 , 73 If untreated, depression and anxiety-related disorders increase the risk of preeclampsia, preterm delivery, IUGR, substance use, maternal suicide, infanticide, psychosis, and homicide. 11

INTIMATE PARTNER VIOLENCE

Intimate partner–related homicide is the leading cause of death in the United States in pregnancy. Screening is recommended at the first prenatal visit and once per trimester. 13 Intimate partner violence increases the risk of miscarriage, placental abruption, premature rupture of membranes, IUGR, and preterm delivery. 13 Family physicians should be aware of the signs of intimate partner violence (e.g., frequent sexually transmitted infections, repeated requests for pregnancy tests when pregnancy is not desired, fear of asking a partner to use a condom), the effect of violence on health, and the increased risk of child abuse after delivery. 13

SUBSTANCE USE

Substance use during pregnancy increases the risk of IUGR, preterm delivery, stillbirth, fetal malformations, and maternal death. 74 The use of prescription opioids complicates 7% of pregnancies in the United States; of these, 20% of patients report misuse. 75 Opioid use in pregnancy increased by 131% from 2010 to 2017 in the United States, and the incidence of babies born with withdrawal symptoms in that time increased by 82%. 76 Fetal alcohol exposure is the leading cause of preventable neurodevelopmental disorders in the United States. 14 However, 14% of pregnant patients report current drinking, and 5% report binge drinking in the past 30 days. 77 Exposure to cigarette smoking in utero increases the risk of sudden intrauterine and infant death. 15

FOOD INSECURITY

Maternal food insecurity increases the risk of poor outcomes (e.g., IUGR, preterm delivery, gestational diabetes, hypertension, depression, anxiety). However, few patients disclose this due to concerns about social stigma; therefore, a universal approach to screening is encouraged. The Hunger Vital Sign tool may be used. 12

Complications of Pregnancy

Gestational diabetes.

Gestational diabetes complicates up to 14% of U.S. pregnancies, with up to 67% of patients developing type 2 diabetes later in life. 78 Racial and ethnic minorities are at the highest risk. 79 Gestational diabetes is associated with hypertension, macrosomia, shoulder dystocia, and cesarean deliveries. 80 Screening for undiagnosed type 2 diabetes at the initial prenatal visit is recommended for people at increased risk 80 ( Table 6 5 , 80 ) . Universal screening for gestational diabetes should occur between 24 and 28 weeks with a one-hour (50-g) glucose tolerance test and, if results are abnormal, should be followed by a confirmatory, fasting, three-hour (100-g) test. 80

HYPERTENSION

Blood pressure should be monitored at each prenatal visit, and education should be provided on preeclampsia warning signs. 5 Patients at increased risk of preeclampsia should be screened for thrombocytopenia, transaminitis, and renal insufficiency, including proteinuria, during the first or second trimester and started on prophylactic daily low-dose aspirin (81 mg) between 12 and 16 weeks 5 , 85 ( Table 6 5 , 80 ) . [Updated] Screening for proteinuria in isolation has little predictive value for detecting preeclampsia. 5 Chronic hypertension (hypertension before 20 weeks) is treated to less than 140/90 mm Hg. 81

PRETERM DELIVERY

Preterm delivery (between 20 and 37 weeks) is a significant cause of neonatal morbidity and mortality, complicating 10.5% of U.S. pregnancies. 2 Modifiable risk factors include prepregnancy BMI (less than 18.5 kg per m 2 and greater than 25 kg per m 2 ), substance use, and short interval between pregnancies (i.e., less than 18 months). 82 Several options are available for the prevention of preterm labor in a singleton pregnancy. 82 Patients with a previous preterm delivery before 34 weeks should have a cervical length assessment starting at 16 weeks through 24 weeks. 82 These patients should be treated with progesterone supplementation (vaginal or intramuscular). In the asymptomatic patient with a short cervix and without a history of spontaneous birth before 34 weeks, vaginal progesterone (200 mg) started between 16 and 20 weeks and continued through 36 weeks is recommended. 82

POST-TERM DELIVERY

Stillbirth complicates 3 per 1,000 post-term (42 weeks or greater) pregnancies. 20 Antenatal testing should be initiated at 41 weeks; if the results are not reassuring, induction of labor is recommended. 20 , 21

Cultural Considerations

Maternity care improves outcomes; however, vulnerable populations (i.e., racial, ethnic, and religious minorities) are less likely to engage in care if it is not culturally centered, which acknowledges the effect of culture on health conditions (e.g., depression) and enhances patient-physician trust. 83 Addressing cultural needs (e.g., doula, community health workers, interpreters) throughout pregnancy helps mitigate barriers and improves outcomes.

This article updates previous articles on this topic by Zolotor and Carlough 1 ; Kirkham, et al. 17 ; and Kirkham, et al. 84

Data Sources: A search was completed using the key terms prenatal care, COVID-19, oral health, pelvic examination, prepregnancy body mass index, pregnancy dating and ultrasound, maternal and paternal age and impact on pregnancy outcomes, aneuploidy screening, inheritance patterns of sickle cell disease and cystic fibrosis, anemia, cell-free DNA analysis, thyroid disease, cervical cancer screening, management of abnormal cervical cytology, screening guidelines for sexually transmitted infections in pregnancy, group B Streptococcus screening, social determinants of health and prenatal outcomes, intimate partner violence, polysubstance abuse, food insecurity, maternity care deserts, hypertension in pregnancy, progesterone for preterm birth prevention, post-term delivery, and preconception care. Also searched were PubMed, Essential Evidence Plus, the Cochrane database, U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, American Cancer Society, American Family Physician , and reference lists of retrieved articles. Search dates: July 1, 2022; February 19, 2023; and June 16, 2023.

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Content of First Prenatal Visits

The purpose of this study was to examine the content of the first prenatal visit within an academic medical center clinic and to compare the topics discussed to 2014 American College of Obstetrics and Gynecologists guidelines for the initial prenatal visit.

Clinical interactions were audio recorded and transcribed (n = 30). A content analysis was used to identify topics discussed during the initial prenatal visit. Topics discussed were then compared to the 2014 ACOG guidelines for adherence. Coded data was queried though the qualitative software and reviewed for accuracy and content.

First prenatal visits included a physician, nurse practitioner, nurse midwife, medical assistant, medical students, or a combination of these providers. In general, topics that were covered in most visits and closely adhered to ACOG guidelines included vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Topics discussed less often included many components of the physical examination, education about pregnancy, and screening for an identification of psychosocial risk. Least number of topics covered included prenatal screening.

Conclusions for Practice

While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study. Identifying new ways to disseminate information during the time constrained initial prenatal visit are needed to ensure improved patient outcomes.

Introduction

A significant and long-standing problem in healthcare is the timing, volume, and variety of care and education that could be covered during busy prenatal visits. Guidelines for the content of the first prenatal visit have been developed and endorsed by a variety of professional and public health organizations for over a century. The most recent guidelines for prenatal care, including first prenatal visits, are the 2014 American College of Obstetricians and Gynecologists (ACOG). Early and complete first prenatal visits are promoted as opportunities for screening, identifying, and addressing risk factors to improve pregnancy outcomes, provide important pregnancy education information, and establish the importance of prenatal care. However, little is known about how these guidelines are actually applied in the first prenatal visit.

There has been a rapid expansion of knowledge about the importance of the mother’s health before and during pregnancy and an increase in the number of topics to discuss within a time limited clinical encounter to adequately care for pregnant women. For example, ACOG recommends that all pregnant women, regardless of age, disease history or risk status, be routinely offered prenatal genetic screening (" ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities," 2007 ). Some research indicates that discussing the importance of breastfeeding during the first prenatal visit may increase rates and duration of breastfeeding ( Chung et al., 2008 ; " Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force recommendation statement," 2008 ). However, most care and education provided to women is decided upon by the individual prenatal care provider. It is unknown what care is typically provided and what topics are discussed, especially in the first prenatal visit. Before any interventions or educational tools are developed to improve how prenatal education and screening options are communicated to women, we first need to understand what care is actually provided and what health education topics are discussed.

The goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother through the determination of gestational age, identification of maternal risks, ongoing evaluation of the health status of the mother and fetus, anticipation of problems and necessary interventions, and patient education and communication ( ACOG/AAP, 2012 ). Early prenatal care also focuses on assessing maternal risk factors to support early intervention, providing of advice, offering health education, and teaching ways to address the minor problems of pregnancy ( Al-Ateeq & Al-Rusaiess, 2015 ). However, guidelines for this content vary greatly and have been criticized for failing to focus on the pregnant woman ( Hanson, VandeVusse, Roberts, & Forristal, 2009 ).

In 1925, the U.S. Department of Labor issued the Standards of Prenatal Care: An Outline for the Use of Physicians ( U.S. Department of Labor, 1925 ). Sixty years later in 1989, the U.S. Public Health Service issued a report describing the components of prenatal care, basing their recommendations on the current scientific evidence ( PHS, 1989 ). Adherence to these guidelines, as well as the 1959 ACOG guidelines, was examined in the late 1980s. Kogan et al. examined providers’ adherence to the subsequently published US P.H.S. 1989 guidelines by interviewing almost 10,000 pregnant women. Almost half of women reported that they failed to receive the recommended early prenatal examinations, laboratory tests, and health education ( Kogan, Alexander, Kotelchuck, Nagey, & Jack, 1994 ). Baldwin, et al. (1994) examined the adherence of 249 prenatal care providers (obstetricians, family physicians, certified nurse midwives) to the ACOG Guidelines of 1959 that had been in place for almost 30 years. They found that the providers followed the well established guidelines on average 80–90% of the time (range 13% to 94%).

The broad categories in these historical documents remain much the same in the most recent guidelines issued by the American College of Obstetricians and Gynecologists (2014) and separately by the American Academy of Family Practice ( Zolotor & Carlough, 2014 ). However, there has been a significant increase in the content of each category with many more patient history questions, laboratory tests, and health education topics recommended on the first prenatal visit. The result of this increased burden in terms of adherence has not yet been examined. The purpose of the current study was to examine the content of the first prenatal visit within a university hospital clinic. Clinical interactions were audio recorded and the content analyzed to identify adherence to the 2014 ACOG guidelines (" ACOG Committee Opinion no. 598: Committee on Adolescent Health Care: The initial reproductive health visit," 2014 ).

Thirty first prenatal visits were audio recorded. The purpose of the recordings was described to the providers and pregnant women as assessing the type of topics covered in the prenatal visit, such as breastfeeding, vitamins, and prenatal screening. Data collection occurred in a Level 3, academic medical center obstetric clinic serving a diverse group of women receiving care under a variety of health care payment plans. All providers of care and patients were eligible for participation in this study. Patients being seen for their first prenatal visit were approached for study consent and enrolled in the examination room. Providers of care were obstetricians (MDs), certified nurse midwives (CNM), nurse practitioners (NPs), and medical students (MS). Staff involved were medical assistants (MAs). Some first prenatal visits included either an MD or NP, an MD and an NP, a CNM, and an MD and a MS. The recorder was turned on when the patient consented and prior to any interactions with a provider. The recordings were stopped when the patient exited the examination room. Audio-recordings were later transcribed verbatim and were used in the analysis. All visits took place between October 2014 and December 2014. The study was approved by the University of Utah Institutional Review Board and all patients signed written informed consent prior to any study procedures.

Audio recording transcripts were read in their entirety by the researchers. ACOG recommendations for content of first prenatal visit topics were used for comparative analysis (see Table 1 . ACOG Guidelines). The transcribed text for all first prenatal visits were uploaded into ATLAS.ti® for analysis. ( Atlas.ti, 2015 ). A qualitative content analysis was used to analyze the data. A distinguishing feature of a content analytic approach is the use of a consistent set of codes to designate data segments that contain similar material ( Elo & Kyngas, 2008 ). Consistent with our work ( Author et al., 2012 ; Author et al., 2011 ), the codes were generated from the data, and rather than using search algorithms, careful readings of the data were performed to generate the codes. Then the codes were systematically applied to the transcripts, with the ability to add codes that might have been missed with the initial development of the codebook. After coding was completed, they were summarized to identify the most frequently reported topics across the clinical visits. We addressed trustworthiness and rigor of the data to maintain data integrity during the analysis through methods of credibility and auditability ( McBrien, 2008 ). Upon completion of the coding, all data were queried within Atlas.ti® and reviewed by the research team. This allowed reviewing, verifying, and auditing the coding schema and associated data.

Percent of Visits – Adherence to ACOG Guidelines Overall (n=30 clinic visits)

After the initial analysis was complete, the content of the clinical visits was compared to the ACOG guidelines for the first prenatal visit (see Table 1 ). Any text addressing any component of each of the ACOG categories was counted as addressing the category. Incidence and density of topics were determined by the frequency of codes. However, because we relied only on verbal content, some aspects of the physical exam may have been missed if the provided did not mention it (i.e. I am taking your blood pressure now.) Descriptive statistics were used to further characterize the adherence to ACOG recommendations in these first prenatal visits by type of provider (see Table 1 ).

The analysis included thirty separate clinical visits of women seen for their first prenatal visit. An unknown number of providers of care were included and some providers could have been included more than once. Data collection was over one month and allowed a range of different providers and patients to be included in this study. Selection of participants and providers was random. Of the providers recorded there were 5 visits that included both an MD and NP, 8 visits with NP only, 14 visits with MD only, 2 with a MD and MS, and 1 with CNM. All participants and providers were English speaking. Demographic data for the patients and providers were not collected. The primary purpose of this study was the visit content discussed and adherence to ACOG guidelines for the initial reproductive visit.

Incidence of Topics Discussed

ACOG Guidelines provide a comprehensive list of topics for education and counseling to be provided at the first prenatal visit. The percent of visits in which adherence to ACOG Guidelines was identified is shown in Table 1 . Identification of adherence included mere mention of a topic and extensive discussion and/or provision of specific ACOG-recommended care or patient education. Yet, the time devoted to each topic was not accessed. In other words, these results do not represent the extent or the amount of time dedicated to the specific recommended content of prenatal care.

In this study, a clinic overview was provided to every woman. This included a number of topics, i.e. schedule of visits, availability of providers, and making appointments. In almost every visit, there was evidence of some history taken or a portion of a physical examination provided, as well as mention of routine blood testing.

Discussion of cervical cancer / pap smears and urine testing occurred in 80–83% of the visits. A confirmatory examination for pregnancy in this sample, largely represented by auscultation of fetal heart tones, occurred in three quarters of the visits. A discussion of routine laboratory testing and available genetic testing was found in 70–75% of the visits. Prenatal vitamins and iron were also routinely addressed in over 70% of visits, and flu vaccine was offered (57%).

Gathering of a family medical history, assessment of and education about alcohol, tobacco, and / or drugs were found in slightly over half the visits. Exercise counseling occurred in about half the visits. As specific complications were not known for each woman, any mention of complications in the transcripts, such as twins or vaginal birth after cesarean, was counted as fulfilling the ACOG recommendation, occurring in 26% of visits. Any discussion of the process of pregnancy was identified as fulfilling the ACOG recommendation of educating the women about the expected course of pregnancy, found in 20% of visits. Psychosocial needs assessment visit guidelines were followed in less than 10%.

None of the recordings indicated that a complete initial history, assessment for pre-term labor risk, or complete physical examination was completed (i.e. abdomen, breasts and inquiries about bladder and bowel functions, weight gain, and vital signs). ACOG guidelines indicate a complete needs assessment should be done. This complete assessment was not found on recordings of any visits although additional visits could have addressed these patient needs. Screening for domestic violence or depression was not found in any recording, with depression rarely addressed in the first prenatal visit. Education on most ACOG recommended first prenatal visit topics (labor & delivery, working, air travel, dental care, over the counter medication use, pets and seat belt use) was rarely or never found on recordings. Psychosocial issues were rarely addressed on the audio tapes. Prenatal classes, while often not attended until late in pregnancy, were never mentioned nor was there an investigation of any barriers to receiving care in any visit. Specific content of the routine laboratory and diagnostic testing was not discussed in the recordings or known to researchers. As no histories of the women were available to researchers, women who were at risk for gestational diabetes (GDM) or pre-term labor were not identified to know who merited education or early screening. GDM screening was not discussed with any woman.

First prenatal visits are often scheduled throughout an MD / CNM / NP’s clinical day, interspersed with other types of pregnancy and gynecologic patient visits. Providers work under time constraints with multiple patients scheduled in quick succession. This can result in abbreviated visits, omission of ideal health education, reliance on other staff to collect information and provide patient education, and addressing only the most obvious problems. Given clinical time constraints, many providers rely on provision of printed materials to patients to compensate for the lack of time available for direct face-to-face patient education. Whether printed materials are an effective or optimal approach to delivering patient education or not, is questionable ( Nolan, 2009 ). Further, some topics may be discussed in future visits to account for the limited time in only one clinical visit.

The study results suggest that several ACOG guidelines are being addressed, particularly those related to medical care and intervention – vitamins and iron, blood and urine laboratory studies, flu vaccine, and screening for cervical cancer. However, the extent of discussion or amount of time dedicated to meeting ACOG recommendations, are unknown. For example, the mention of “genetic screening” in the transcribed audio recording was coded and reported as “addressed” during the prenatal visit. However, genetic screening is a complex topic and it is unknown if it was fully discussed during the visit or was it merely mentioned that information about genetic screening as provided in the printed material distributed to the patient.

It is unknown what information was already contained in the EMR, although the EMR format is known to allow for the documentation of all the ACOG recommended information. Initial historical information, family history, genetic history, and risk of pre-term labor could have already been in the EMR or data could have been entered outside the examination room. Video recordings, rather than audio recordings, could have revealed that a physical examination occurred, as there was no specific mention of a completed physical examination in the audio recording. Finally, as discussed above. first visit prenatal education recommended by ACOG may have occurred in a different formast, for example, printed materials distributed to patients. Further, some of the patients may have undergone a “confirmatory pregnancy” appointment and topics not discussed in this recorded visit could have occurred as well as in future visits. Audio recordings revealed that packets of prenatal information were often given, however the exact content is unknown.

The prenatal visit discussions in this study were focused on information gathering with mostly closed ended questions used by providers, usually resulting in patient responses of “yes or no”. This style of questioning discourages full and meaningful responses that could have provided additional information of importance to patient care. The providers in this study addressed concerns that were expressed by the women, but rarely asked women about their concerns or fears. Discussing a woman’s concerns and fears can reveal risk factors that should be addressed or a further discussion can allay fears once identified. Many providers referenced the authoritative recommendations of health care profession groups, such as ACOG and others, without further discussion. An explanation of the risks, benefits, and/or alternatives to that recommended care was rarely offered.

A larger question that should be considered is how the content of the ACOG recommendations can be addressed while including patient driven needs and preferences in these guidelines. Many of the components of the ACOG Guidelines are based on tradition with a limited number of topics supported by careful research ( Zolotor & Carlough, 2014 ; Kirkham, Harris, & Grzybowski, 2005 ). Further research is needed to explore the value of all of the components, with the goal of including only those that have proven value. Women’s needs and preferences have not been routinely included in published guidelines ( Hanson et al., 2009 ), implying that these are of lesser importance or additional avenues outside the clinic visit need to be explored to address patient.

Lastly, forming relationships with patients requires time, the use of open-ended questions, and repeated visits. It is unreasonable to assume that such a close relationship will occur at the first prenatal visit. This study demonstrated the issues of provider time constraints based on their recorded comments are related to lack of adherence to ACOG’s education recommendations,, and lack of screening for unstated problems.

Limitations

This study took place in one outpatient clinic in a Level 3, academic medical center obstetrics clinic. Other practice settings, such as a private office, birth center or home birth setting, may structure first prenatal visits very differently. The majority providers of care were MDs and no comparisons can be made of their care to the care of the few CNMs or NPs in this study. Further, the content of the visit was descriptively compared between different providers. It would be interesting to assess how different professionals prioritize different topics during time limited clinical encounters as well as how patients’ driven questions influence the topics covered. Researchers lacked access to knowledge about existing information in the EMR or when the EMR was used. Audio recordings missed the visual information and nuances of a video recording, which would have provided additional information about first prenatal visit content. Lastly, content analysis did not address the extent to which ACOG guidelines were followed, nor the amount of time dedicated to provision of care or patient education. Future studies should include these aspects of ACOG guideline adherence to better understand the effectiveness of prenatal care and include additional prenatal visits.

This study demonstrated that standard ACOG guidelines for first prenatal visit content were inconsistently followed at one site by one group of providers based on audio recordings. Providers more closely adhered to ACOG guidelines that addressed vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Content addressing many components of the examination, education about pregnancy, and screening for an identification of psychosocial risk was identified less often. Providers routinely used an interview style that did not elicit extensive information. While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study.

Acknowledgments

We would like to thank the University of Utah College of Nursing Research Committee for helping fund this study.

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  • Bastian LA, et al. Clinical manifestations and diagnosis of early pregnancy. https://www.uptodate.com/contents/search. Accessed Oct. 18, 2022.
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  • Prenatal care and tests. Office on Women's Health. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-and-tests. Accessed Oct. 18, 2022.
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  • Lockwood CJ, et al. Prenatal care: Patient education, health promotion, and safety of commonly used drugs. https://www.uptodate.com/contents/search. Accessed Oct. 18, 2022.
  • Stages of pregnancy. Office on Women's Health. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/stages-pregnancy. Accessed Oct. 18, 2022.

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Your first antenatal visit

7-minute read

  • Antenatal visits check the wellbeing of you and your baby during pregnancy.
  • During your first visit, your doctor or midwife will check your health.
  • They will also work out when your baby is due to be born.
  • During your visit you will learn how to keep healthy during your pregnancy.
  • Regular antenatal care is likely to positively affect the health of you and your baby.

Antenatal visits check the wellbeing of you and your baby during pregnancy. Antenatal care throughout your pregnancy is likely to positively affect the health of you and your baby.

Your first antenatal care appointment is an important one. During your visit, your doctor or midwife will:

  • confirm your pregnancy
  • check your health
  • give you some information that you will need in the months ahead

You will also be able to talk about the type of care you want during your pregnancy.

When should I make my first appointment?

It’s best to have your first antenatal visit before 10 weeks into your pregnancy. Ideally this will happen when you are about 6 to 8 weeks pregnant. This is because there are lots of things to learn about. Also, some tests are recommended early in your pregnancy.

Your first appointment may be with a midwife or your doctor. It may be at a clinic or hospital — you can choose.

What does an antenatal visit involve?

Taking your medical history.

During the visit, your doctor or midwife will ask about your health. This includes finding out about:

  • any prior pregnancies
  • any illnesses or operations you’ve had
  • what medicines you’re taking, including those from a pharmacy or supermarket
  • if you have any current health problems
  • if you are allergic to any medicines

Your doctor or midwife will ask you if you:

  • drink alcohol
  • take recreational drugs
  • are stressed
  • have any signs of depression or anxiety
  • about the support you may get from people at home and work

These questions aren’t to judge you. The more your doctor or midwife knows about you, the better they can support you during your pregnancy.

It’s up to you whether you answer these questions. Anything you say will be kept in confidence.

If you are experiencing family violence you should let them know. It’s important to get professional help and they can support you to do this.

Your family medical history

Finding out about the health of your family is also important because it may affect you or your baby. This includes any family history of:

  • genetic conditions
  • chronic illnesses such as diabetes

You may wish to do screening tests for certain genetic conditions . You can talk about this with your doctor or midwife.

What tests will I have?

Your doctor or midwife will check your health and measure your:

  • blood pressure

They may suggest a urine (wee) test to see if you have a urinary tract infection (UTI) or any kidney problems.

You will also be offered a blood test to check your blood group and rhesus factor. They will also check for:

  • infectious diseases — rubella
  • sexually transmitted infections (STIs)
  • bacteria that may affect your baby — group B streptococcus
  • infections that can be passed on through blood-to-blood contact — hepatitis C and HIV

Some STIs that can affect your pregnancy don’t have any symptoms. It’s possible to have an STI and not know.

Find out more about the check-ups, tests and scans you can have during your antenatal visits.

If you have any questions about these tests, ask your midwife or doctor.

Finding out about your baby

Your doctor or midwife will work out how many weeks you have been pregnant. This will let them work out the due date of your baby.

If you’re not sure when your last period was, they may book a dating scan . This is an ultrasound that will help figure out which week of pregnancy you are in.

Tests are available to check for some problems that may affect your baby. You don’t have to have these tests — it’s up to you. Your midwife or doctor will tell you about the tests and how much they will cost.

Discussing your antenatal care options

During your first appointment, your midwife or doctor will give you information about antenatal care. They will talk with you about which model of care you would like for your pregnancy and birth. You'll be able to discuss:

  • who will be your main maternity carer
  • where you would like to receive your antenatal care
  • how many antenatal visits you will have and when
  • where you would like to give birth
  • where to find local antenatal classes or education sessions

How can I have a healthy pregnancy?

Your midwife or doctor will talk to you about keeping healthy during your pregnancy. They will also ensure you have good support and care.

This may cover:

  • help to stop smoking or stop drinking alcohol (if needed)
  • advice about healthy eating , exercise and weight gain
  • advice on which vitamins and minerals you should take during pregnancy
  • referrals to support services if you need them

They will answer questions about any issues that worry or concern you.

If this is your first pregnancy, The Australian Pregnancy Care Guidelines advise you have 10 antenatal care visits. If there are complications with your pregnancy, you may need to have more visits.

If you’ve been pregnant before, The Australian Pregnancy Care Guidelines advise you have 7 antenatal care visits. Again, if you have any complications with your pregnancy, you may need more visits.

first nurse visit pregnancy

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

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Last reviewed: November 2022

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You receive antenatal care from your GP, midwife or obstetrician. You’ll be offered tests and scans and your health and your baby’s will be checked.

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Once you are pregnant, your first antenatal appointment will ideally take place when you are about 6 to 8 weeks pregnant.

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Maternity care in Australia

If you are pregnant or planning a pregnancy, find out what care, support and services may be available to you in Australia.

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Advice about Eating Fish

For Those Who Might Become or Are Pregnant or Breastfeeding and Children Ages 1 - 11 Years

Advice about Eating Fish: Mom feeding her toddler fish

FDA and EPA have issued advice regarding eating fish ‡ .

This advice can help those who might become or are pregnant or breastfeeding as well as parents and caregivers who are feeding children make informed choices when it comes to the types of fish that are nutritious and safe to eat. This advice supports the recommendations of the Dietary Guidelines for Americans .

The advice features a chart that makes it easy to choose dozens of healthy and safe options and includes information about the nutritional value of fish. A set of frequently asked questions & answers provides more information on how to use the chart and additional tips for eating fish.

‡ This advice refers to fish and shellfish collectively as “fish.”

Read the full advice below or download in PDF . 

This chart can help you choose which fish to eat, and how often to eat them, based on their mercury levels.

Advice About Eating Fish - Chart Thumbnail

Enlarge in PDF

Supporting Materials | Education Resources for Consumers and Educators

En español and Additional Translations

Fish provide key nutrients that support a child’s brain development

Fish provide key nutrients that support a child’s brain development .

Learn which nutrients in fish support child development

Eating fish can provide other health benefits too

Eating fish can provide other health benefits too.

Learn more about health benefits                                                                                    

The Dietary Guidelines for Americans recommends eating fish as part of a healthy eating pattern

The Dietary Guidelines for Americans recommends eating fish as part of a healthy eating pattern .

Learn more about Dietary Guidelines and fish

Choose a variety of fish that are lower in mercury.

Choose a variety of fish that are lower in mercury .

Learn which fish are lower in mercury

Fish provide key nutrients that support a child’s brain development.

Fish are part of a healthy eating pattern and provide key nutrients during pregnancy, breastfeeding, and/or early childhood to support a child’s brain development :

  • Omega-3 (called DHA and EPA) and omega-6 fats
  • Iodine (during pregnancy)

Choline also supports development of the baby’s spinal cord . Fish provide iron and zinc to support children’s immune systems . Fish are a source of other nutrients like protein, vitamin B12, vitamin D, and selenium too.

divider

Fish intake during pregnancy is recommended because moderate scientific evidence shows it can help your baby’s cognitive development.

Strong evidence shows that eating fish, as part of a healthy eating pattern, may have heart health benefits .

A healthy eating pattern consists of choices across all food groups (vegetables, fruits, grains, dairy, and protein foods, which includes fish), eaten in recommended amounts, and within calorie needs. Healthy eating patterns include foods that provide vitamins, minerals, and other health-promoting components and have no or little added sugars, saturated fat, and sodium.

Healthy eating patterns that include fish may have other benefits too. Moderate scientific evidence shows that eating patterns relatively higher in fish but also in other foods, including vegetables, fruits, legumes, whole grains, low- or non-fat dairy, lean meats and poultry, nuts, and unsaturated vegetable oils, and lower in red and processed meats, sugar-sweetened foods and beverages, and refined grains are associated with:

  • Promotion of bone health – decreases the risk for hip fractures *
  • Decreases in the risk of becoming overweight or obese *
  • Decreases in the risk for colon and rectal cancers *

The Dietary Guidelines for Americans recommends eating fish as part of a healthy eating pattern.

The Dietary Guidelines for Americans recommends:

  • At least 8 ounces of seafood (less for children § ) per week based on a 2,000 calorie diet.
  • Those who are pregnant or breastfeeding consume between 8 and 12 ounces per week of a variety of seafood from choices that are lower in mercury .

Choose a variety of fish that are lower in mercury.

While it is important to limit mercury in the diets of those who are pregnant or breastfeeding and children, many types of fish are both nutritious and lower in mercury.  

What is a serving ? As a guide, use the palm of your hand.

Pregnancy and breastfeeding: 1 serving is 4 ounces  Eat 2 to 3 servings a week from the "Best Choices" list  (OR 1 serving from the "Good Choices" list).    

Fish Serving Size Hand: 1 serving = 4 ounces

Childhood: On average, a serving is about:  1 ounce at age 1 to 3  2 ounces at age 4 to 7  3 ounces at age 8 to 10  4 ounces at age 11  Eat 2 servings a week from the “Best Choices” list.    

Children Silhouette

Enlarge in PDF  |  View Text Version  |  En español

What about fish caught by family or friends?  Check for  fish and shellfish advisories  to tell you how often you can safely eat those fish. If there is no advisory, eat only one serving and no other fish that week. Some fish caught by family and friends, such as larger carp, catfish, trout and perch, are more likely to have fish advisories due to mercury or other contaminants. 

This advice supports the recommendations of the  Dietary Guidelines for American s , which reflects current science on nutrition to improve public health. The  Dietary Guidelines for Americans  focuses on dietary patterns and the effects of food and nutrient characteristics on health. 

* There is  moderate scientific evidence of a relationship  between the eating pattern as a whole and the potential health benefit. 

§For some children, the amounts of fish in the  Dietary Guidelines for Americans  are higher than in this FDA/EPA advice. The  Dietary Guidelines for Americans  states that to consume those higher amounts, children should only be fed fish from the “Best Choices” list that are even lower in mercury – these fish are anchovies, Atlantic mackerel, catfish, clams, crab, crawfish, flounder, haddock, mullet, oysters, plaice, pollock, salmon, sardines, scallops, shad, shrimp, sole, squid, tilapia, trout, and whiting. 

Advice revised October 2021

Supporting Information

  • Questions & Answers
  • Technical Information on Development of the Advice about Eating Fish
  • FDA and EPA’s Response to External Peer Review on the FDA-EPA’s Technical Information
  • External Peer Review Report of FDA-EPA’s Technical Information  
  • FDA Closer to Zero Action Plan

Text Versions of the Best Choices, Good Choices, and Choices to Avoid Lists of Fish

Consejos sobre el consumo de pescado

Embarazo y lactancia: El Consumo de Pescado (Infografía)

Niños: El Consumo de Pescado (Infografía)

Kit de herramientas para redes sociales: Consejos de la FDA y la EPA sobre el consumo de pescado

El consumo de pescado: una guía para las familias hispanoamericanas

Seguridad de los alimentos para mujeres embarazadas, sus bebés por nacer y niños menores de cinco años

Versiones de texto de las mejores opciones, buenas opciones y opciones a evitar listas de peces

Additional Translations

Translations of Fish Names

عربي (Arabic)

简体中文 (Chinese, Simplified)

中國傳統 (Chinese, Traditional)

Français (French)

Hmoob (Hmong)

ខ្មែរ (Khmer)

한국어 (Korean)

Português (Portuguese)

Tagalog (Tagalog)

Tiếng Việt (Vietnamese)

Resources to Use FDA/EPA’s Fish Advice

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