Prenatal care is a safeguard for all couples preparing for birth, and especially for an out of hospital birth. This is not only important for your health and that of your baby, but affords the opportunity for you to learn about the changes within your body as the pregnancy develops. Each time we meet for a prenatal visit, we will complete a prenatal chart to follow your progress, and discuss any questions or concerns. I may ask you to obtain your medical records concerning any previous pregnancies, births, surgery or hospitalization(s).
Initial History and Physical Exam (IH&P)
Your first prenatal visit is usually scheduled 9-10 weeks after the first day of your last menstrual period.
This initial visit takes from 1 ½ to 2 hours and includes:
1. A complete medical history
2. Risk Screening (a series of questions concerning your health, and that of your mate and family, which helps identify factors which should be considered when choosing your attendant and place of birth
Screen for Midwifery Care
Screen for Healthy Start Services
Screen for Genetic and Medical Risk Factors
3. Complete Physical Examination
Head to toe complete physical assessment of all systems, including a breast and pelvic exam
4. Labs (subject to discussion and informed refusal if you prefer)
- Cervical Cultures for Chlamydia and Gonorrhea
- Urine Pregnancy test (if not done prior)
- Blood drawn and Urine Sample obtained for:
- Blood Group and Rh factor Antibody Screen
Rubella Titer (German Measles) HIV CBC (Complete Blood Count) Hepatitis B Differential with Platelet Count RPR (Syphilis) Varicella Antibody (Chicken Pox) Toxoplasmosis (if you have cats)
Sickle Cell Screen (if appropriate)
•If you are unsure of your dates, or there is a discrepancy between your dates and your uterine size, you will be offered an ultrasound for confirmation of the pregnancy and the expected date of the birth (EDD).
5. Discussion of the Prenatal Visit Schedule and Recommended Lab Tests
6. Diet Discussion and Diet History
7. Danger Signs – When and How to contact your Midwife
8. Financial Agreement
Return Prenatal Visits – once per month until 28 weeks, then every two weeks until 36 weeks, then weekly until Birth or 41 weeks.
All Prenatal Visits include:
1. Assessment of weight gain
2. Discussion of diet
3. Blood Pressure
4. Urinalysis for Glucose, Protein, Leukocytes, and Ketones
5. Assessment of uterine/fetal growth
6. Assessment of fetal size, position, presentation, and fetal hearts as appropriate for the stage of pregnancy
7. Discussion of Exercise and Activity
8. Discussion of Problems/Concerns
10-12 Weeks (or two weeks after your Initial Prenatal Visit)
Review of Diet History Discussion of AFP Triple Marker/Quad Screen Test or Amniocentesis
AFP Triple Marker/Quad Screen
Referral for physician for Genetic Counseling and Amniocentesis if indicated and desired
20 Weeks and 24 Weeks
Discussion of Blood Glucose Challenge Test to be drawn at 28 weeks
Glucose Challenge Test, repeat of complete Blood Count, including Platelet count, Repeat RPR (syphilis), repeat HIV and Hepatitis B test, and Antibody Screen (if you are Rh Negative), and RhoGam injection (if you are Rh Negative & desire it).
Ultrasound – if you desire an ultrasound, I recommend one at 28-32 weeks for fetal development and placental localization.
**VBAC candidates will be required to obtain an ultrasound and consultation with my consultative physician. **
Discuss writing a Birth Plan
Receive and discuss Birth Supplies List Birth Certificate Application Schedule and obtain directions for Home Visit at 36 weeks
36 Weeks – Home Visit and Birth Plan Discussion
All expected to attend the birth (midwife, assistant, birthing parents, support people, etc.) will meet where you plan to birth, and discuss what will happen. We will review your Birth Plan, your Birth supplies, your Emergency Care Plan, discuss Vitamin K, eye ointment, and Group B strep testing, and answer any questions. This visit usually takes about 1 – 1 ½ hours.
Vaginal Culture for Group B Strep ** If you have had a previous baby with a GBS infection, or a urinary tract infection during pregnancy due to Group B Strep, you are at higher risk for passing this infection to your newborn. We will discuss the culture during your Home Visit, and answer any questions. *If you have a history of Genital Herpes infection (HSV), you will be offered a culture for Herpes on a weekly basis until the birth, or a prescription for anti-viral medication to take until the Birth. Repeat blood draw for Hemoglobin and Hematocrit and Platelets ** Repeat Antibody Screen if you are Rh Negative
Gentle pelvic exam as desired (Though I rarely do them because they don’t provide enough information before labor to make it worthwhile.) At 40 Weeks, we will discuss the protocols for Post Dates Pregnancy, including Testing and Herbal Alternatives/Inducement of Labor
41 weeks and 4 Days
Referral to OB for continued Care
I fully acknowledge the obligation of the mother and father to obtain information concerning any or all of these tests or procedures, so that an Informed Decision can be made as to any inherent risk connected with the test or procedure versus the benefit (information) which can be obtained. You have the right to refuse any test or procedure, but I do ask that you make an informed decision, and accept responsibility for the lack of information (and potential consequences) that might otherwise have identified a potential problem. For example, should you desire not to have an ultrasound, I request that you be aware of the Risks and Benefits of ultrasound, and the type of information that can be obtained through this medium, and accept that we will not have access to that information. We can decide whether that information is necessary (for your comfort level or mine), in order to pursue an out of hospital birth.
LABOR AND BIRTH
If you think you are in labor, or membranes rupture (water breaks), please page me. I will come to your home as soon as you wish, but I do ask that you contact me early in labor, so I may notify my assistants, and make any necessary arrangements. I am always available by cell phone or pager. Please do not hesitate to call, regardless of the time or day/night. I would rather come too early a hundred times, than too late once. I will bring one Birth Assistant with me, and that Assistant will be with me for the 36 Week Home Visit to become familiar with you and others who will be present for the Birth. I also frequently have Midwifery Students who are completing their clinical training with me. You will also have the opportunity to meet with them prior to the Birth, and you can decline their presence at any/all prenatal visits, or the birth.
Licensed Midwives assist only in normal childbirth, and I will call for emergency medical backup if you or I feel it is necessary. My care includes labor guidance, insuring labor progress with vaginal examinations (though I rarely do very many, and you can decline), monitoring of the fetal heart rate (I have an underwater Doppler for Water Labor/Birth), checking for fetal position and presentation, perineal massage and support, birth of the infant, delivery of the placenta, monitoring and initial comprehensive examination of the mother’s and baby’s condition postpartum. I will remain with you and your newborn for at least 2-4 hours following the Birth, and I am assured that both of you are stable and comfortable. Of course, I am always available by pager/phone if a problem or concern should arise.
POSTPARTUM AND NEWBORN CARE
Written and verbal postpartum instructions for the mother and newborn will be given to the parents and any other caregivers after the Birth. I will return to your home to check both you and your newborn at 24 hours and 72 hours. Please feel free to call me with any questions or concerns about your health, or that of your baby, or breastfeeding concerns. I would always rather speak to you for what turns out to be a minor problem. If you hesitate to call because of the hour or situation, a minor problem can become a major one due to the delay. You have my cell phone and pager numbers so that I can always be contacted. In the event that I am not available (i.e. vacation, family emergency, etc.), appropriate coverage will be provided. I will also complete the application for the Birth Certificate (which includes the social security application). You will need to schedule an initial appointment with your pediatrician within 4-6 days following the Birth. I offer the metabolic (PKU) testing for your newborn at the 48-72 hour visit. I do not perform circumcision, and will refer you to your choice of physician, should you desire that service.
My services also include a postpartum examination, done at 4, 5, or 6 weeks, which will include a physical examination, Pap Smear, breastfeeding assessment, and discussion of contraception.
Blood Group and Rh factor – to determine what Blood Group (A, B, AB, or O) you belong to, and whether or not you have the Rh factor Antibody Screen – to detect any abnormal antibodies in your blood, some of which can cause Hemolytic Disease of the Newborn Complete Blood Count (CBC) with Differential and Platelet Count –a baseline blood screen to determine your general health, immunity status, iron levels, etc. RPR – Syphilis screen – whether or not you have been exposed to Syphilis, a sexually transmitted disease which could affect you and your baby Sickle Cell Screen – a genetic blood disorder in which your capacity to carry oxygen can be greatly reduced. This condition can greatly affect both you and your baby. This disease occurs more commonly in the black race, and those with American Indian background. Viral Screens – A variety of viruses can affect you and your body. If you have been exposed to a virus, your body builds specific antibodies to that specific virus. It is possible to detect and identify antibodies to the following viruses which could cause complications during pregnancy”
1. HIV – screen you for exposure to the AIDS virus which can cross the placenta and cause numerous complications in your baby.
2. Rubella – to screen you for exposure to German Measles (Rubella), a virus which could also affect your baby, and can cause birth defects.
3. Varicella – to screen you for exposure to Chicken Pox (Varicella) which can affect your baby.
4. Toxoplasmosis – to screen you for exposure to the toxoplasmosis virus which can be transmitted through cat feces, and raw/undercooked meat. This can affect your baby’s development.
5. Hepatitis B – a virus which can affect your liver function, and can also be transmitted to the baby.
Pap Smear – a scraping of cells from the cervix or vagina, which can be examined at the laboratory for a wide range of abnormalities from infections to vaginal, cervical, and in some cases, uterine cancer.
Chlamydia Culture- a cervical culture to detect this virus which can cause cervical and vaginal infections, abnormal Pap Smears, and infections in the uterus, possible premature labor, or spontaneous abortion.
Gonorrhea Culture - a cervical culture to detect this infection which can cause birth defects, and many of the same complications as Chlamydia.
Genital Culture – a swabbing of the cervix or vagina to determine if a bacterial infection is present.
Group B Strep Culture – a culture of the vagina and rectum to determine the presence of a bacterial infection caused by Group B Streptococcus. This infection can cause pneumonia in a newborn who acquires the bacteria during the birth.
ALPHA FETOPROTEIN BLOOD TEST / TRIPLE SCREEN / QUAD SCREEN
You will be offered an Alpha Fetoprotein Blood Test or Triple Screen or Quad Screen, which is performed at around 15-17 weeks of pregnancy. This blood test was developed to screen for your risk of having a child with a Neural Tube Defect – a developmental problem which occurs when the spinal column does not completely close as it is formed (i.e. Spina Bifida, Meningomyelocele, Anencephaly, etc.), or a child with a genetic defect (Down’s Syndrome is the most common one). I will draw a sample of your blood, and the results are usually available within one week.
Results are reported as your Risk Factor of having an affected child, and are calibrated using your age, race, weight, your estimated gestational age of pregnancy, whether you are diabetic or not, and whether this is a single or multiple pregnancy. A negative test results is merely one in which your result is consistent with the statistical chance of someone else with all the factors matching yours. Therefore the result is not a Positive or Negative one, but a numerical risk. False positives and false negatives can occur. Levels reported to be unusually high can be associated with incorrect dating of the pregnancy, a multiple pregnancy, first trimester spotting or bleeding, diabetes, or a Neural Tube Defect. Levels which are reported as lower than expected, can be associated with chromosomal defects, usually Trisomy 21 (Down’s Syndrome). However, there is a much stronger correlation between an abnormally high level and a problem pregnancy, than an abnormally low level and a problem pregnancy. Additional testing to clarify the situation could include an ultrasound to accurately date the pregnancy, rule out twins, or the cause of any abnormal bleeding, and to check for developmental defects of the spinal column, and an amniocentesis to check the genetic makeup of the fetus. It is also possible to run the AFP level on the amniotic fluid (much more accurate than on maternal blood samples). It is important to remember that the AFP test is only a screening test, and it is designed to screen for a specific problem. An abnormal test level does not automatically mean that your baby has a problem, merely that the pregnancy is at higher risk for the problem. If you would not act on the information obtained from this test, you should consider whether or not you wish to have the test done.
If you are or will be at least 35 years old when your baby is born, or you have had a prior baby with a genetic or developmental problem, you will be offered an Amniocentesis to screen for genetic defects, which become more common as your age increases. The incidence of having a child with a genetic defect rises significantly from age 35-42 and older. Other risk factors may also place the fetus at increased risk, and these will be discussed at your Initial OB Visit. Amniocentesis is performed at 15-16 weeks of pregnancy, in the physician’s office, under ultrasound guidance. After a short ultrasound to locate the fetus and the placenta, the physician will clean and drape your abdomen, and use a very thin needle to aspirate a small amount of amniotic fluid from the sac surrounding the baby. Most women find the procedure mildly uncomfortable, but not painful. The amniotic fluid is constantly being produced, and the level will be replenished quickly. You may experience some cramping after the procedure, and should stay fairly quiet for the remainder of the day. The procedure is not without risk, however, the risks will be explained to you in detail before the physician performs the Amniocentesis. Amniotic fluid AFP levels are usually available within a few days after the procedure. The genetic banding (karyotyping) takes from 10-14 days, and is reported out according to the karyotype (i.e. 46XX or 46XY). The total number of chromosomes is given, any abnormalities are noted and described, and the sex is noted (XX=female, XY=male). A normal karyotyping indicates that the chromosomes have been screened for known chromosomal abnormalities and none were seen. The type of information available from chromosomal karyotyping is increasing almost on a daily basis, as new genetic markers are isolated. If you decide to have an Amniocentesis, the consulting physician will provide you with detailed information concerning any abnormalities. No one test, or combination of tests, can insure that your baby will be 100% healthy. However, each test can contribute to the information base available about your baby. If you would not act on the information obtained with this procedure, consider whether the risk of the procedure is worth the potential benefit.
A blood test to assess your iron levels (your body’s ability to carry oxygen around to the cells). Every muscle (including the uterus) requires oxygen to work efficiently, so keeping a healthy level of iron available is important, not only during labor, but afterwards.
GLUCOSE CHALLENGE TEST
This is a blood test performed at 26-28 weeks of pregnancy to detect those women with Gestational Diabetes, an insulin deficiency which produces blood sugar levels higher than normal. The fetus cannot process glucose – it relies upon the mother’s glucose for survival. If the glucose levels remain too high in the mother’s (and therefore the fetus’) bloodstream, the warning signs of diabetes can occur, just as they would in juvenile or adult onset diabetes. Complications can include impaired circulation, obesity (large or macrosomic babies), impaired brain function, eye malformations, disruptions in vision, and mental retardation. There is a normal expansion of maternal blood volume which is completed by approximately 22-24 weeks. As the blood volume expands, occasionally the glucose regulation system based in the pancreas, fails to keep up with the demands of the increased blood supply and the result is “Gestational” or “Pregnancy-Induced” Diabetes. Properly controlled with diet, or insulin in some form, most mothers with Gestational Diabetes will have normal pregnancies and infants. The majority of those mothers will not be diabetic after the pregnancy is over, but a small percentage of them will continue to be diabetic after the pregnancy, despite treatment. Gestational Diabetes is often controlled simply with dietary changes, but the ramifications for uncontrolled diabetes for both mother and fetus can be impressive. Therefore, it is recommended that all pregnant women be screened with the Glucose Challenge Test. A simple measured dose of 50 mgs. of glucose beverage, or food which is the equivalent of 600 kilocalories is given to the client, and a blood sample is drawn exactly one hour later. The test results should fall within established parameters. If the test is high, a three hour glucose tolerance test may be recommended, or the client may be advised to follow a strict diet to limit the amount and timing of glucose intake. Blood test results are usually available with a couple of days.
RhoGam is an injection that is available to interrupt the formation of any anti-Rh antibodies that might be formed if a mother who is Rh Negative is carrying an Rh positive fetus, and there is a mixing of the two blood types. The most common time for this mixing of blood types to occur is during the birth. But it is possible that the mother and baby’s blood could mix prior to the birth, and the RhoGam shot effectively halts the production of antibodies which could be harmful to the mother’s next baby. The RhoGam Shot is administered after a blood test to indicate if there are any antibodies present (either at 26-28 weeks or after the birth). The shot is administered into the hip, and there is rarely any reaction. The baby’s blood type will be determined form a sample of the cord blood taken immediately after the birth. If the mother is Rh negative, and the newborn is Rh positive, the mother will be offered a RhoGam injection at one of the postpartum visits to neutralize any antibodies that would form, thereby protecting babies in any future pregnancies. All maternal blood samples are checked for the presence of fetal blood to determine if RhoGam is required, and how much.
GROUP B STREP CULTURE
Group B Strep is a bacteria which often exists in the intestinal tract. It can also be present in the mother’s vagina, causing vaginal odor or discharge, premature labor, uterine infections, or no symptoms at all. If the baby is infected with Group B Strep as it comes through the vagina during the birth, the bacterial infection can cause severe newborn infection – including pneumonia, blood infections, and even death. If the mother has a positive Group B Strep Culture before the birth, she will be offered a choice of treatment alternatives or she may choose not to be treated. All newborns are monitored during the neonatal period for any abnormal conditions (including respiratory distress or GBS infection).
One way to assess fetal well-being is to monitor the baby’s heart rate over an extended period of time, and to note how well the heart rate responds to movement (stress). Usually this test is performed when there is a question of whether the placenta is continuing to perform optimally, or a question of how well the baby is doing, or after 41 weeks. At some point, the placenta outgrows its usefulness and begins to break down. It is no longer to provide adequate nutrition to the fetus, and begins to calcify as a sign of aging. If you listen to the fetal heart rate over a period of time (usually 15-20 minutes), and compare variations in the heart rate to fetal movements, there should be a predictable change in the heart rate associated with the movement (a reactive non-stress test).
If the pregnancy passes 41 weeks, a reactive Non-Stress Test can reassure the midwife or backup physician that the fetal-placental unit is functioning adequately. The mother is brought to the physician’s office about one hour after a meal, and hooked up to the external fetal monitor. Two belts are placed around her abdomen, one to monitor the heart rate, and one to monitor any contraction activity. After 20 minutes or so, the strips should indicate heart rate reactivity in the presence of uterine activity or fetal movement. This is a “reactive” test. If there is little or no reaction to contractions or fetal movement, the test is “non-reactive”. Non-reactive tests are repeated after mother eats and drinks. Occasionally the fetus is simply in a sleeping or inactive state, but it is important that the fetus is doing well. Induction of labor is indicated if the fetus fails to respond adequately to activity or contractions.
Immersion in a tub of warm water (deep enough to cover your tummy) has been shown to promote relaxation, which promotes shorter labors and less perineal trauma (tears).
Birth Tubs are available for use during your Labor and/or Birth.
What about Safety in Out of Hospital Births?
Studies in Florida, the United States and Europe have consistently shown that the low risk mother, having a planned Home Birth with a trained attendant, is at the same or lower risk of complications (in either mother or baby), as a woman choosing a Hospital Birth. Each client must research the risk factors and be comfortable with her own choice.
What is a low risk woman?
A low risk pregnant woman has no current serious medical condition (diabetes, high blood pressure, uncontrolled asthma, epilepsy or obesity). She has received regular prenatal care with this pregnancy, and has not developed any condition indicating that she or her baby would have difficulty during labor or Birth.
Who does prenatal care?
A Midwife can confirm the pregnancy, perform all prenatal examinations, and order all appropriate laboratory testing and ultrasounds.
Who can be present for the Birth?
Siblings, grandparents, friends or a doula can be invited at the discretion of the mother. The Midwife will have on assistant (who is also a certified doula).
What if there is a problem?
Midwives are trained to recognize and prevent complications, if at all possible. In Florida, Midwives are certified in CPR and Neonatal Resuscitation, and carry emergency medications, oxygen, and suturing supplies and appropriate anesthesia. Emergency medical services must be available within thirty minutes, and Obstetricians and Pediatricians can provide additional care at the hospital, if transport is necessary.
How much does it cost?
In general, Home Birth costs less than a hospital birth. You will receive a current Fee Schedule in your Information Packet if you inquire about services.
Laboratory fees, Ultrasound, Prescription Medications, and Home Birth Supplies are additional.
All insurance companies operating in Florida are required to reimburse clients for fees associated with a Home Birth, to the extent of your policy.
Do I qualify for a Home Birth?
Schedule an initial consultation, and we will discuss your medical and pregnancy history to determine your risk status, and answer any questions.