This checklist is meant to help future parents understand and navigate the pre-pregnancy and pregnancy period. It summarizes all of the basic care and recommendations that you might be expected to receive. It is relevant for all pregnant women and does not cover any specific disease treatments, interventions, or follow up testing. I believe we are entering a COVID baby boom and thought this information would be useful for patients and providers alike.
Much of our treatment regarding pregnant women is based on the “standard of care," expert opinion, and the way we have always done things. Only a few things we recommend during pregnancy have been shown to improve pregnancy outcomes in real clinical trials. As it is 2020, this is a sad truth. All routine tests should be studied in clinical trials to assure they are not causing more harm than good. This was found to be the case in counting fetal movements. This practice led to unnecessary stress, further testing, did not improve outcomes, and actually caused harm. Do not count fetal movements.
Pre-Pregnancy
- Start taking folic acid 0.4-0.8 mg per day. This has been shown to reduce neural tube defects in the baby. It is present in most multivitamins and any woman of child bearing age is encouraged to take folic acid (vitamin B9).
- Get in the best shape of your life. Exercise, eat healthy, get your mental health in good order, and address any substance addiction problems.
- Treat any diseases you have with aggressive lifestyle interventions to avoid or minimize the need for medications while pregnant.
- Get up to date on all recommended vaccines.
Getting Pregnant
- Women undergo menstrual cycles that are usually around 28 days but can vary greatly.
- Midway through the cycle, ovulation occurs. This is when your ovaries spit out an egg that could potentially join with a sperm cell to make a baby. You may have noticed a change in your vaginal mucous around this time. The 3 days before ovulation and 1 day after is the time when a pregnancy is most likely to occur. You and your partner should have sex every day during this time period. Since it can be hard to know exactly when ovulation occurs, having sex regularly while not on your period can be a good idea.
- Mineral oil can be a great lubricant option as this does not affect sperm or the flow of vaginal mucous. Mineral oil is also my go to for lubrication during delivery!
- Try and get pregnant for one year before seeking medical help if mom is < 35 years old. If mom is 35 or older, try for 6 months before seeking help.
- Enjoy trying to get pregnant. Sex should be fun! If it is not fun, you are probably doing something wrong. Trying to get pregnant can cause a lot of stress and I have seen it hurt relationships. Try and relax, this is a process.
- Remember to give this process time, do not stress out after a couple months of not getting pregnant.
- Avoid tobacco, alcohol, marijuana, and other illicit drugs while trying to conceive and throughout your entire pregnancy. An occasional serving of alcohol, such as a glass of wine, is ok! I would say a couple a week at most. The safe limit for alcohol is not known. In larger amounts, alcohol and other drugs can have devastating consequences on unborn babies.
Finding out the Babies Due Date
- The baby's due date is 280 days or 40 weeks after the first day of your last menstrual period. Even though ovulation does not usually occur until 2 weeks after the first day of the last menstrual period, we still count this toward the babies gestational age. Most women will take a pregnancy test a few days after they miss their period and the baby will already be about 5 weeks at this time.
- A first trimester ultrasound between 7 and 10 weeks of pregnancy is the most accurate way to tell babies age. This is because ovulation can be unpredictable.
- Use the first trimester ultrasound size measurement called crown-rump length to date baby if available.
1st Prenatal Visit Testing
- At this first visit, a number of different tests are often performed. These are listed below. It is important to find an obstetrical provider that you like and trust because you are going to be spending a lot of time with them over the next 8 or so months.
- Testing for anemia or low red blood cells by testing a CBC blood test.
- Blood type ABO, RhD, and antibody testing using a blood test.
- TSH blood test to check the function of the thyroid.
- Comprehensive metabolic panel blood test to test electrolytes, liver, and kidneys.
- Chlamydia infection test.
- Gonorrhea infection test.
- Hepatitis B infection test.
- HIV and syphilis infection tests, which is repeated in the 3rd trimester for high risk woman such as those who use IV drugs or have multiple sex partners.
- Urinalysis test to assess your urine.
- Rubella immunoglobulin to test for rubella immunity (from vaccinations).
- Varicella infection test for woman who have not received the vaccine.
- Tobacco, alcohol, and drug use screening should be performed. Women should be advised to stop immediately if not already doing so. An occasional alcoholic drink is probably ok.
- If due for a PAP smear or high risk HPV, this may be offered to assess for cervical cancer.
- Oral exam for periodontal disease is often performed due to the increased pre-term labor rate with poor dental hygiene.
- Providers should ask about intimate partner violence to assure mom’s safety in the home. This is often missed and should not be.
- If you are at high risk for diabetes due to a history of diabetes, a history of gestational diabetes, obesity, or other risk factors, you will be tested for diabetes using an A1c blood test at this first visit.
- Culture of the urine for bacteria. This is treated with antibiotics if positive even in the absence of symptoms to avoid future infection.
- Checking for Hepatitis B, syphilis, HIV, RhD blood type, and a urine culture are the most important tests because they are supported by evidence to improve pregnancy outcomes.
Ongoing Screening Throughout Pregnancy
- Blood pressure, weight, and body mass index will be followed throughout pregnancy
- Mom's legs will be checked for swelling (edema) throughout pregnancy.
- Fetal heart rate will be checked with a doppler machine after 10 weeks at all visits.
- The height of the uterus from the pubic symphysis to the uterine apex will be measure after 20 weeks gestation. The height in cm should be about the same as the baby’s weeks of gestations. 30 weeks = 30 cm.
- Moms should be screened for depression before, during, and after pregnancy. This can be a tough time. Do not forget this!
- Other than blood pressure monitoring and depression screening, most of this testing is just what we have always done and has not been shown to improve pregnancy outcomes.
Pregnancy Visits
- Most obstetric providers in the United States see pregnant moms every 4 weeks. After 28 weeks of pregnancy, visits increase to every other week. After 36 weeks, visits increase to once weekly. However, decreasing the number of prenatal visits to just 4 total resulted in no adverse outcomes over the standard of care.
Genetic Testing
- This is optional.
- I recommend that parents discuss what they would do about any abnormal genetic test, prior to undergoing testing.
- For instance, many people might choose to terminate a pregnancy, particularly if a severe chromosomal abnormality like trisomy 13 is detected.
- The best genetic tests on the market are blood tests (from mom) that test for cell free placental DNA. Basically a bunch of DNA fragments from the placenta, which shares the same DNA as the baby are floating around in mom’s blood.
- These tests often look for trisomy 21 (Downs syndrome), trisomy 13 (Pataus syndrome), trisomy 18 (Edwards syndrome), sex chromosome abnormalities like Turner syndrome, and 22q11.2 deletions (DiGeorge syndrome). These tests can also tell you the sex of your baby.
- Cell free placental (fetal) DNA tests are extremely accurate. All other genetic testing strategies are vastly inferior. If someone tries to stick a needle inside your uterus the answer should be no in 2020!
Vaccines During Pregnancy
- Get the flu vaccine while pregnant.
- TDaP (tetanus, diphtheria, acellular pertussis) vaccine booster is generally given between 27 and 36 weeks of pregnancy to all moms.
- Give the measles, mumps, and rubella (MMR) vaccine after pregnancy if mom is not rubella immune at the first prenatal visit. The MMR vaccine is a live attenuated vaccine. These vaccines have living organisms in them which have been mutated to become less virulent or infectious. Pregnant woman are advised to avoid live attenuated vaccines while pregnant due to the theoretical risk of infection from these weaker genetically modified organisms.
Later Screenings
- A comprehensive anatomy ultrasound is often performed between 19 and 21 weeks of pregnancy. This can pick up on certain problems like congenital heart disease. There is no evidence that this improves pregnancy outcomes but most people will get it.
- All women should be checked for gestational diabetes (diabetes that develops during pregnancy) between 24-28 weeks. This is often done with a glucose tolerance test where mom drinks 50g of glucose and her blood sugar is tested 1 hour later. If this is abnormal, additional testing is needed. Sometimes this test is repeated later in pregnancy for moms at high risk for diabetes.
- Hemoglobin and hematocrit blood tests are checked again around 28 weeks to assess for anemia.
- Moms are tested for Group B Strep bacteria with a vaginal swab and culture between 35 and 37 weeks of pregnancy. About 1 in 4 moms are positive and this means they will receive antibiotics during labor. These antibiotics help prevent some babies from becoming very ill from Group B Strep bacterial infection after delivery.
- Make sure baby is head down with an Ultrasound at 36 weeks.
RhD blood type Negative Moms
- RhD negative moms should receive the medication Rhogam at 28 weeks and again within 72 hours of delivery if the baby is not known to be RhD negative. Give Rhogam to any RhD negative mom following traumatic injury.
When to Go to the Hospital and Have a Baby
- If you have a sudden gush of water from your vagina, this either means you urinated on yourself, or your water (amniotic fluid sac) has broken. When your water breaks, you need to go to the hospital.
- If you develop regular contractions that are increasing in strength and do not go away with walking or a few sips of red wine, this is a reason to go to the hospital.
- Both of these scenarios might mean it is time for you to have a baby. Do not be discouraged if you are sent home and told to come back. This happens a lot.
Diet During Pregnancy
- Pregnancy will cause women to be hungry and even hangry at times. They need to be fed on demand.
- A reasonable strategy is to add 100 calories to your daily diet during the first trimester, 200 calories to your daily diet during the second trimester, and 300 to 400 calories a day during the 3rd trimester. However, this is highly variable and depends greatly on pre-pregnancy weight. The above is a good strategy for a women of normal weight (BMI 20-25). Some morbidly obese women (BMI > 40) may actually be advised to lose weight during their pregnancy. Some morbidly obese women have carried children to 40 weeks, not even realizing they are pregnant.
- Eat healthy high quality food during your pregnancy.
- Eat lots of fruits and vegetables, but be sure to wash them thoroughly and wash your hands before eating.
Food to Avoid in Pregnancy
- Do not eat the artificial sweetener saccharin. It crosses the placental barrier and accumulates in fetal tissue (other artificial sweeteners are thought safe).
- Ingest < 200 and certainly < 300 mg of caffeine a day.
- Avoid unpasteurized dairy products to avoid infections from harmful organisms like Toxoplasma, Listeria, and Brucella.
- Avoid delicatessen foods like meat spreads, pate, soft cheeses, deli meat, hot dogs, smoked salmon, and any ready-made foods that live in your refrigerator. These foods can all be eaten if cooked thoroughly and eaten immediately. Listeria can grow on these foods even at cold temperatures. Make sure your refrigerator temperature is < 40F or < 4C.
- Thoroughly reheat any leftovers.
- Avoid Latin style soft cheeses like Queso Fresco and Cotijo as these carry the highest burden of Listeria. These Latin soft cheeses account for more than half of cases of Listeria from soft cheese. In general Listeria risk is very low, about 3 per 100,000 pregnant women. However, Listeria can be devastating to the fetus and this is why the above recommendations exist.
- Many people will tell you that pasteurized soft cheeses are ok. However > half of Listeria soft cheese outbreaks have occurred in pasteurized soft cheeses.
- Avoid raw eggs and undercooked chicken to avoid the bacteria Salmonella.
- Avoid eating raw fish, unless the quality is known to be extremely high (very high quality sushi).
- Avoid raw shellfish. Ok to eat if cooked thoroughly and enjoyed immediately.
- Limit your intake of cold water fish as not to take in too much mercury. Shark, swordfish, mackerel, tuna, tilefish, whale, and other cold water apex predators tend to have the highest mercury load. While high levels of mercury from the ingestion of pilot whales showed harm in one cohort study in the northern Atlantic, these whales were shown to have tremendously high levels of mercury compared to most fish and were ingested daily. Other studies have shown that eating fish a few times a week is actually good for the baby, likely because of the nutritional benefits. Think about eating things like Alaskan salmon and anchovies. It is sad that we have polluted our great oceans to such a profound degree with toxic mercury from burning coal and gold mining. Unfortunately, whales and fish cannot avoid this toxin like we can!
- Many women break all of the above rules and have normal, healthy kids. My wife and I have decided to follow them though, even though soft cheese is very important to us. Overall risk is low for most all of the above.
Exercise
- Keep exercising regularly throughout pregnancy. Labor is called labor for a reason. The better you are conditioned the better you will do. Avoid adding extremely strenuous activities like marathons, if this was not part of your regular routine prior to pregnancy.
Sexual Intercourse
- Continue to have sex throughout pregnancy. This can improve partner bonding and feels great. Having sex later in pregnancy can stimulate labor. This can be a good thing if you are past 38 weeks and want to get the party started. However, do not fear having sex later in pregnancy prior to 38 weeks for this reason. If you have a condition known as placenta previa, your provider may advise you to avoid vaginal intercourse. However other types of sex can still be safely enjoyed.
Activities to Avoid
- Air travel is generally avoided after 36 weeks of pregnancy
- Avoid activities that may cause belly trauma. Things like physical sparing in martial arts, high impact activities like skiing (especially aggressive downhill), and skydiving should be avoided.
- Woman are advised by most sources to avoid scuba diving during pregnancy due to the risk of decompression sickness. There is no real evidence to support this claim though.
- Avoid hair treatment and hair dyes. This is controversial and information seems very conflicted. I did not do a deep dive into this topic, but maybe need to.
- Avoid exposures to toxic chemicals, organic solvents, heavy metals, and environmental pollutants. If you work in a factory or laboratory where harmful chemicals are utilized, review all such chemicals for safety in pregnancy. If safety is not well documented for a given substance in pregnancy, practice avoidance. Workplaces can often contain hazards most people would not even consider outside of pregnancy. Check in with your occupational safety officer and consider visiting an occupational medicine doctor if you still have concerns. Wonder Medicine can help with this!
- Avoid unnecessary medication and all medications known to be harmful in pregnancy. If you have pain, take acetaminophen (Tylenol). Ibuprofen and other non-steroidal anti-inflammatory medications should be avoided in pregnancy.
- Avoid ionizing radiation exposures like x-rays.
- Take great caution with driving. Use a 3-point seatbelt. Driving will hurt many more pregnant women every year than most all of the foods to avoid listed above.
- Avoid herbal substances like ephedra and saw palmetto during pregnancy. Think of herbs like medication (they often are) and research any of them you are considering taking for safety in pregnancy. Ginger is known to be very safe and helps with nausea.
- Avoid hot tubs and saunas in the first trimester. Getting mom hot has been associated with neural tube defects and potentially other problems. Like most things listed on this blog post, the evidence is weak though.
Hopefully this information helps you on your pregnancy journey! Thank you for reading!
Wonder Medicine in Boise, Idaho can take care of woman before and during pregnancy. We can help women get pregnant and even handle most all prenatal care. However, we cannot handle pregnancy emergencies and cannot perform deliveries, at least at this time.
Please check out the Full Scope podcast, at FullScope.org for more information. The podcasts on preventative screenings in obstetrics, listeriosis, and the pregnancy checklist can provide interested readers with more information on pregnancy topics.
Author
Bill Brandenburg, MD
Wonder Medicine’s Longevity and Performance Program improves your lifespan and healthspan with a research-driven proactive program that focuses on the big picture of your health so you can perform at your highest potential.
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