Many women and girls find a first gynecologic visit intimidating. As providers, we understand, and strive to make each and every visit as comfortable as possible. Many women are surprised to discover that the American Congress of Obstetrics and Gynecology recommends a first papanicolaou (pap) test at age 21. There are a variety of reasons to see a gynecologist, including well woman exams, menstrual concerns, fertility concerns, pelvic pain, and visits for contraception. For a first visit with us, please schedule time ahead of your appointment to complete paperwork, either online or in person. Please bring important written questions or concerns with you, we will be happy to answer them! You will be meeting your provider in a comfortable relaxed setting before having to change out of your clothes. Some first visits are complete in this stage and no exam is necessary. Other times, an appropriate examination is required.
Generally a complete well woman exam involves all the elements of a physical exam, including a clinical breast examination, and a pelvic examination. The pelvic examination is usually two parts. First, inspection of the cervix is performed with a speculum. This also allows a papanicolaou (pap) smear to be performed as well as other tests such as cultures or swabs to evaluate for various conditions. The speculum portion of the exam is done in a gentle manner with the smallest speculum that will allow visualization. If you would like to inspect a speculum or any equipment prior to the examination, please ask! We are happy to show you what we are doing and why. The second portion of the examination is the bimanual examination, in which a provider will use a finger or two to feel the internal female structures; the cervix, uterus, ovaries, and tubes. This lasts under a minute for most examinations, and gives the provider much information about the size and shape of the internal organs; abnormalities such as ovarian cysts, masses, fibroids, or adenomyosis; and the presence or absence of infections.
Usually a complete well woman examination lasts about ten minutes or less, with the majority of the visit time scheduled for discussion of concerns, or answering questions. Results from the pap test or other results are available within a week most of the time, and you will be contacted either via mail or by phone regarding results. We highly value the opportunity to help keep healthy women healthy, and a well woman exam is one of our best tools to accomplish this.
If you’re reading this then you are either planning to become pregnant, or you are pregnant. Congratulations! We are excited about caring for you during this intense and exciting time in your life.
We usually recommend that a pregnant woman come to see us at around eight weeks following her last menstrual period. An exception would be for serious symptoms noted sooner, such as significant bleeding or pain.
At the first obstetric visit, we like to perform ultrasound to evaluate the pregnancy and establish a due date. You will also meet with your provider. For obstetric care, we have physician providers and certified nurse midwives. Generally all providers care for patients with low risk conditions. For higher risk pregnancies, most women will see or at least consult with physician providers. Some examples are women who are carrying twins, have significant medical conditions during pregnancy such as thyroid disease, diabetes, high blood pressure, or history of previous cesarean deliveries or uterine surgery.
Your provider will review your complete medical history, do an examination if needed, and review ultrasound results with you. Most of our patients have lots of questions, and we schedule time to answer them. You may find some of your questions are answered below in this information.
To standardize and precisely date each pregnancy, we use “weeks” and days pregnant as opposed to “months.” Pregnancy starts with the first day of the last menstrual period, and lasts an average of 40 weeks which is also the “due date.” Of course, most women actually become pregnant about two weeks after the last menstrual period. The system we use is historical from before ultrasound and highly sensitive lab tests were used, and the last period was the most reliable method for “dating the pregnancy”. We recommend a first visit around 8 weeks, and then a visit every 4 weeks until about 28 weeks. Following that, we see pregnant patients every 2 weeks until 36 weeks, then weekly thereafter until delivery. If a higher risk pregnancy is noted, additional or more frequent visits may be required. Another term you may hear is “Trimesters” which divide pregnancy into thirds. These are generally 13 weeks long, with the last being 14. For example 0-13 weeks is the first trimester, 14 to 26 weeks is the second trimester, and 27 weeks on is the third trimester. We consider a “term” gestation to be 37 weeks or later, and “full term” to be 39 weeks, with a due date on the 40th week.
We usually perform a first trimester ultrasound at 8 weeks to establish that the pregnancy is healthy, and determine whether there is one or more than one fetus. An “anatomy” survey is performed at around 20 weeks. This “big” ultrasound visualizes all the internal organs, and inspects the growth of the infant to ensure health. These are “routine.” However, there are many other reasons your provider may want ultrasounds in addition to these, including concerns about large or small infants, observation of the developing fetus, observation of the placenta or fluid, or other reasons. Your provider will communicate with you about need for any additional ultrasounds.
Pregnancy “Do’s and Don’ts”
Most pregnant women are told lots of “rules” from books, the internet, and friends and family about what is safe in terms of diet, exercise, and activity during pregnancy. What follows here is a discussion of common “rules” people hear and our philosophy for keeping you and the baby safe.
Intercourse: Intercourse (sexual activity) is considered safe throughout pregnancy except in rare individuals with high risk conditions (placenta previa, preterm labor or ruptured membranes, and cervical incompetence.) Your provider will tell you when it is not safe to have sexual relations. Intercourse often causes mild spotting or light bleeding especially in the first trimester. In the absence of worsening cramping, this is normal and does not require an emergency room visit. The surface cells on the cervix are highly hormone sensitive, and pregnancy commonly makes these cells bleed when disturbed by pap smears, exams, or intercourse. This does not pose a risk to the fetus. In the latter part of pregnancy, intercourse often causes contractions. Experts do not believe that intercourse causes labor.
Exercise: Exercise is recommended during pregnancy, including aerobic and non-aerobic workouts. We do not recommend any activities that could be “dangerous” such as contact sports, sports with big pressure changes (such as scuba diving or skydiving,) or sports which are likely to cause injury. I tell my skiers and snow-boarders that you may be the best skier in the world and still get hit by the worst skier on the slopes. It IS safe to have a heart rate over 140, but we recommend you should discontinue aerobic exercise that you cannot talk through, or if you feel short of breath or lightheaded. For weight lifting, exercise that you can “breathe” through without grunting or holding your breath is recommended. Breathing through the exercise is recommended for pilates and yoga as well as weightlifting.
Healthy Diet and Weight Gain: We recommend eating a balanced and healthy diet full of fruits and vegetables, lean protein, and rich in complex carbohydrates. Most pregnant women experience some cravings as well as some food aversion during pregnancy, and this is normal. A guideline for “ideal body weight” for women before pregnancy is the following formula. For women over 5 feet tall, start with 100 pounds for 5 feet, then add 5 to7 pounds for each inch over 5 feet to determine an ideal body weight range. For example, a woman who is 5 feet 6 inches should weigh 100 + 30 to 42: so her ideal body weight is 130 to 142 pounds or so. For women starting pregnancy at a normal weight, women will likely gain between 25 and 35 pounds. For overweight women, 15 to 25 pounds of weight gain is recommended. For obese/severely overweight women, under 15 pounds is recommended. For women under their ideal body weight, 35 to 40 pounds are recommended.
Dietary risks: Many women are concerned about eating fish. On the one hand, oily fish like cod and salmon are rich in omega 3 fatty acids, which are very healthy and essential to growth of normal brain and nerve cells. On the other hand, all fish have some level of mercury – an environmental toxin which is higher in longer-lived, top predator fish. The Monterey Bay Aquarium website: http://www.montereybayaquarium.org/cr/ cr_seafoodwatch/download.aspx has a free “seafood watch” brochure with up to the date information about recommended seafood and mercury content. Generally, large, long-lived fish like shark, swordfish, king mackerel, tilefish, and large tuna are higher risk. Higher risk fish can be consumed safely at 2 servings (about 6 ounces) weekly without great concern. Lower risk fish, such as local salmon, cod, halibut, and shellfish, can be consumed safely up to 5 times per week. “What about sushi?” Well, consumption of raw seafood puts people at risk of two main infectious risks: a food poisoning producing vomiting and diarrhea (low risk overall), and a very low risk of parasites (worms). While these are both treatable in pregnancy, many experts recommend avoiding sushi or raw shellfish entirely. We recommend you discuss this with your individual provider.
More dietary risks: Pregnant women are 10 to 30 times more likely than nonpregnant women to get food poisoning. Most bacterial food poisoning is mild and self limited. One exception is a bacterium called Listeria Monocytogenes. This organism causes severe illness and even death in a high percentage of infected individuals. The infection can harm or kill a developing baby. It is an organism found on animal skin (barnyards.) As a result, this can infect unpasteurized milk products (raw or fresh cheese) or appear in mixed meats which are not cooked at high temperature (smoked or cured meats.) We recommend consuming only pasteurized milk products and well cooked meats. A cold turkey, ham, or roast beef sandwich is extremely unlikely to be contaminated and is considered safe. Consult with your provider for more information.
Hydration during pregnancy: Pregnant women commonly have dizziness especially in the second trimester. This is due to the hormone progesterone, which relaxes little muscles surrounding the arteries. This results in a lower overall blood pressure. To decrease the effects, we recommend good hydration during pregnancy. Another excellent way to combat dizziness is to change a portion of fluid intake to an electrolyte containing beverage (Gatorade, Powerade, or similar). The easiest way to determine if a woman is well hydrated is to examine her urine. Should the urine be light in color, this is an excellent sign of good hydration.
Medication Safety in Pregnancy: In order to label a medication “safe,” a drug manufacturer must extensively test and study a medication in a specific patient population. It is neither ethical or advisable to do this in pregnant women. As a result, the only “safe” medication in pregnancy is prenatal vitamins, which have been tested in this way. This does NOT mean that no other medications are safe, only that they cannot be labelled for pregnancy. We have extensive databases regarding medications and risk posed to mother and developing babies. Please inform your provider about any medication you may be taking at a first visit. We welcome questions about medication safety prior to pregnancy as well, and love “preconceptual visits,” for this purpose.
In regards to medications we recommend, we generally stick to medications categorized as “category B.” Category B medicines have a long history of safe use in pregnancy, with no associated concerns for birth defects, developmental problems, or harm to mother or fetus. These medications have been extensively observed in humans, and also no animal testing (such as in pregnant rats) has shown harm. Many of these medications are administered to newborn infants. Tylenol, most antihistamines, and penicillin are some examples. Please ask us about safe medication use in pregnancy, and call us with questions!
“Call Schedule”: One of our greatest sources of pride as providers at Northwest Women’s Clinic is that we take a personal interest in being available for our own patients. Over 7 in 10 women in our care are delivered by the individual provider caring for each patient. This means that your provider would be available any day that he or she works in clinic, and after hours too! How can we do this? Each provider takes “call” for his or her patients every day that the provider works. For days off, weekends, and holidays, there is a “backup” on call provider. Midwife patients generally are cared for by their midwife, but the backup is occasionally one of our physicians. Physicians are always available for a high risk pregnant woman or a midwife patient needing specialized intervention. We carefully have crafted our practice and partners so we have a very similar medical management for patients. While we have different personal styles, our medical management is very standardized. This ensures top-notch care no matter which provider you visit. The “down side” to our constantly striving to care for our own patients is the risk of a changing provider schedule. Many times we are called out of clinic for deliveries or emergencies, and that means patient schedules often get rearranged. We apologize for any inconvenience, and endeavor to give patients excellent options for either shifting appointment times, rescheduling, or occasionally seeing another provider for scheduled visits when their personal provider is not available.
How do I contact my provider?
We keep the process simple. Calling the main clinic phone number 24 hours per day will get you in touch with us. During clinic hours, our medical assistants and providers are available. Providers usually are limited in returning phone calls at break times or after clinic. As a result, a “best bet” with a question or concern is to discuss this with our trained medical assistant staff. For more complex concerns, providers make every effort to return phone calls in a timely fashion, but because they also may be called out of clinic for emergencies or deliveries, not all calls are answered on the day of the call. After hours, an “answering service” answers calls from the same phone number, and then contacts your provider via pager or cellular phone.
After hours phone calls should be urgent or emergency type calls (calls that cannot wait until the next clinic day). We strive to answer all phone calls and concerns in a timely manner. Occasionally a provider is in a delivery or surgery and may take more than 30 minutes to respond. Please call back should there be any delay. We will call you back!
Overall, we are honored and excited to provide pregnancy care for our patients. We look forward to aiding in the healthiest outcomes for mothers, infants, and families.