This is the second part of an eight-part series focused on pregnancy and receiving prenatal care at Landstuhl Regional Medical Center. The first part of the series discussed services for couples trying to get pregnant and can be found at https://www.army.mil/article/211143/.

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Even the slightest possibility of a new baby could send a hopeful mom-to-be running to the store to pick out nursery colors, but for many expecting parents, the whirlwind of "what's next" can sometimes steal the spotlight of that moment the home pregnancy test turns out positive. For patients at Landstuhl Regional Medical Center and LRMC's outlying primary care clinics in Kaiserslautern and Baumholder, understanding the next steps of the pregnancy process is vital, especially for a military community so used to change.

"It's important that every woman who thinks she may be pregnant knows what to do next," said Air Force Capt. Alaina Tookes, the assistant chief nursing officer in charge of the LRMC Obstetrics and Gynecology Clinic. "Because our patient population moves around quite often, pregnancies and the prenatal process may be different here at LRMC than how it was at their previous military treatment facility or civilian hospital, so the more we inform our patients, the better their pregnancy experience."

Tookes said that the first thing a woman should do if she thinks she is pregnant is to contact her primary care manager to order an official pregnancy test. A routine pregnancy test given at the Baumholder, Kleber or LRMC Family Medicine clinics are usually completed within two hours and her care team will notify her of the results.

When a clinic-administered pregnancy test is positive, the patient's PCM will order a consultation request to the LRMC OB-GYN clinic, essentially transferring her primary care from the home clinic to OB-GYN. The transfer process is usually completed within 24 to 72 hours, so patients are encouraged to call the Appointment Line around the third day after they received their positive pregnancy result from the clinic.

FIRST APPOINTMENTS
The first appointment in OB-GYN will include a dating scan, an ultrasound to confirm the pregnancy and establish the gestational age which then estimates the due date. Once this appointment is complete, the patient can then schedule the New Prenatal Class (NPCL), previously referred to as the intake appointment.

During the NPCL, which lasts about 45 minutes, patients are introduced to the OB-GYN clinic and receive information about prenatal care. Patients are also educated about the different types of prenatal provider options that LRMC offers.

The NPCL nurse will gather history and demographic information on the patient, and an online account is created for TRICARE Online Secure Messaging if one does not already exist. This tool allows patients to communicate with their care team, view lab results and request appointments and prescription refills.

PRENATAL PROVIDER SERVICES
Pregnant patients have the option to choose to see either an obstetrician, a team of nurse midwives or join OB Group Care, commonly known as Centering. Generally speaking, most pregnancies that have been determined to be high-risk will be managed by an obstetrician. Low-risk pregnancies can be managed by both obstetricians and nurse midwives.

The OB Group Care option is recommended for women with low-risk pregnancies and provides the opportunity for patients to receive their OB care in a group setting with others who are due to deliver their babies around the same time. Participants in these groups form bonds and share questions and experiences with each other throughout the course of their pregnancy. The same team of midwives are committed to each OB group, ensuring a consistency in providers throughout the pregnancy.

"OB Group Care appointments are longer and encourage shared discussion and pregnancy education," said Tookes. "We also have guest speakers who address topics such as lactation and breast feeding, nutrition and physical therapy."

Tookes also noted that throughout the course of a woman's pregnancy experience at LRMC, she may see a variety of providers during each prenatal visit to allow her to become acquainted with the OB-GYN team.

"A woman can go into labor at any moment and her normal provider may not be available for the delivery," said Tookes. "It's important to us that she is comfortable with everyone on our team. However, if a patient requests appointments with a specific provider, this will be accommodated as best we can based off of the provider's availability."

FIRST PHYSICAL EXAM
Upon completion of the first appointment, the dating scan, patients should book their physical exam appointment to coincide with 10 to 12 weeks gestation. This appointment is the longest appointment over the span of her prenatal care and consists of additional medical history inquiries, a pelvic exam and a Pap test if needed.

Significant others or birth partners are encouraged to attend this appointment as patients are given ample time to ask questions of their providers.

MONTHLY PRENATAL APPOINTMENTS
For normal pregnancies, patients will be scheduled for monthly visits with their provider or OB Group Care. During these routine visits, patients can expect to be weighed and have their fundal height measured -- the distance between the pubic bone and the top of her uterus. The provider will also monitor fetal heart tones and discuss prenatal education based off of the patient's gestation.

In total, most patients will have approximately eight prenatal appointments. Patients with complicated pregnancies can expect to have additional appointments as determined by their providers. Following the baby's birth, new moms will have one or two postpartum follow-up appointments depending on their method of delivery (vaginally or via cesarean section) or any issues encountered during the birth.

ULTRASOUNDS
At about 18 to 20 weeks of gestation, patients will receive an anatomy ultrasound, ordered during a prenatal visit and completed in the LRMC radiology clinic. For patients with pregnancy complications, the ultrasound is performed in the perinatal clinic, which is located within the OGBYN clinic. During the anatomy scan, the ultrasound technician takes a close look at the baby and uterus. In addition to a taking a number of measurements, in most cases, the technician may be able to identify the sex of the baby.

Most pregnancies will consist of only the initial dating scan and the second trimester anatomy scan. Additional ultrasounds will be ordered at the provider's discretion.

During the ultrasounds, children under eight years old must be accompanied by another adult, and may need to be escorted from the room if they become disruptive during the exam.

"We know that during ultrasounds, especially when we are able to determine the baby's gender, many moms want their whole families to be part of that special moment," said Tookes. "It is important, however, that the ultrasound techs are able to safely and accurately obtain information on the baby and mom, so we do ask that if other children get restless in the room that another adult is able to take them to the waiting room."

WHAT TO BRING TO APPOINTMENTS
During the New Prenatal Class, or intake appointment, patients will receive a "pregnancy passport" -- a log that contains information from each prenatal appointment in addition to pregnancy education -- and should bring it to each appointment.

Diabetic patients should also bring their diabetic log containing blood sugar information.

"I also recommend patients bring a list of questions for their provider," said Tookes. "Regular prenatal appointments are the perfect time to address concerns as well."

SICKNESS AND EMERGENCIES DURING PREGNANCY
While many pregnant women are lucky recipients of the "pregnancy glow," there are also many more who experience sickness. For pregnant patients, primary care needs are addressed in the OB-GYN clinic; patients do not return to their home primary care clinic and PCM until after their six-week postpartum visit. Patients can call the OB-GYN triage line to speak with a nurse or schedule an appointment.

Any obstetrical emergencies that occur prior to 20 weeks gestation will be evaluated in the emergency room. Emergencies that occur after 20 weeks gestation will be evaluated in the Labor and Delivery ward located in building 3763, ward 7B.

While each pregnancy is different for every woman, the prenatal appointment timelines will rarely fluctuate and the clinic schedulers will do everything they can to accommodate patient preferences.

"Pregnancy is an exciting time," said Tookes. "It becomes less stressful when you know what to expect."
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OB-GYN Triage Line: DSN 314-590-5839, CIV 06371-9464-5839

More information on the LMRC OB-GYN Clinic can be found online at http://rhce.amedd.army.mil/landstuhl/services/obgyn.html

The next part of the LRMC pregnancy series will focus on high-risk pregnancies.