Early Pregnancy through to birth, what you need to know about prenatal care in Israel including how to choose, when to visit and what to expect from your OBG.
Guest post on VenoSupport by: Michal Finkelstein RN CNM
B’Sha’ah Tovah! You’re expecting! When a couple first discovers this exciting news, it can be exciting, scary, and overwhelming at the same time. Whether it is a first or a fifth pregnancy, each time is special; each baby is a unique individual. Especially daunting for couples may be the fact of being far from family or a familiar setting where they had people to rely on and a clear understanding of the medical bureaucracy.
First of all, don’t worry. Israel has a very good medical system; you just have to know how to work it. We will try to sort some of that out for you.
Shortly after a missed period, a woman usually does a home pregnancy test, which when done properly, is 99% accurate. One does not need to use the first urine of the morning and results are just minutes away! Most women will not even be feeling anything out of sorts until two to three weeks after a missed period, but I often suggest to a newly pregnant woman to follow a few basic guidelines, even before a potential bout of morning sickness sets in, to keep feeling well and ward off nausea.
- Eat small, frequent snacks that are carbohydrate-based and salty. Pretzels, crackers, dry cereals are often the staples of a 1st trimester diet.
- Don’t allow your stomach to ever be empty even if you are nauseas and don’t have an appetite. This will only make you feel worse.
- Try popsicles, soda, anything that keeps you hydrated. If you have vomited more than 18-24 hours straight, without eating or drinking, go to the emergency room.
- Cut open a lemon and deeply breathe in the scent. Open your windows or go outside – even in the winter. Fresh air is really helpful.
- This will pass! Look at a calendar; 12-14 weeks from the 1st day of your last period should be a relief.
- Everyone feels something different and each pregnancy is different. It does not reflect on the health of the pregnancy or the viability of the baby.
- Continue taking your folic acid (400meq.) every day, until week 12.
Prenatal Care in Israel: Choosing a doctor
Choosing an obstetrician will depend on which health fund you are in and of course where you live. Unlike the United States, a woman does not take into account where she plans to deliver as she will rarely take a private doctor or the doctor who is caring for her prenatally. Most women are delivered by competent midwives staffed by the hospitals with in-house medical backup.
Taking a private doctor for a delivery is costly but recommended in certain complicated cases. However there may be times during a pregnancy or in any question of medical crises, that an expert second opinion is recommended. Upgraded insurance to the standard HMO policy, what is referred to as mashlim, makes this affordable.
Word of mouth is the best reference. If you are not happy with your choice for whatever reason, then you can and should switch. However, you usually have to wait for the three-month insurance period to expire before switching. If you are very displeased with your doctor, a phone call to the office of the district head doctor’s office will usually net you permission to override this provision.
Remember, the system in Israel is basically socialized medicine. Your doctor will usually not make himself available by phone for questions or emergency situations. If you have a medical emergency during the daytime hours, call your HMO hotline, the Moked, and ask where to go for care. If is night-time, or Shabbat, go to the emergency room. If you just want to ask a question, you can call the clinic where your doctor is scheduled to be, and leave a message with the nurse or secretary.
Ideally, you should be seeing your doctor or health care provider every 4 weeks. Realistically, either because of scheduling conflicts on the part of the couple or the medical side or because of over-booking, the space between appointments can often stretch out to every 6 weeks. But when viewed within the context of doctor’s visits + prenatal testing, a pregnant woman does not usually go longer than 4 weeks without being in touch with a medical professional.
For instance, while you are having your blood drawn or at an ultrasound appointment and you realize that you haven’t had your blood pressure checked or urine checked by “dip-stick” for protein, sugar, and acetone; ask the nurse on staff to do this and write it in your prenatal records.
You will be given a card or booklet to carry with you which lists lab results and other pertinent details of your care. In the 9th month, in the US, women are invited weekly to their doctor for internal exams and monitoring. Here in Israel, internal exams (pelvic exams) are not routinely performed throughout the pregnancy unless there is a medical need.
Prenatal Tests in Israel
We will basically divide the pregnancy into three trimesters and outline the standard clinic visits as well as ultrasounds and blood tests. In addition, there are other more advanced tests* that may be advised by your doctor. These advanced tests are not as routine, a couple needs to know they exist, but are not necessarily part of the standard prenatal care in Israel for a low-risk, healthy pregnancy.
First Trimester (0-12 weeks)
- Ultrasound [abdominal] between the weeks 7-10 from the first day of the last period. This will be the most accurate measurement of your baby’s size and gestational age and reduce unwarranted medical intervention later on because of unclear dates or doubts if the baby is overdue. This will also give a view, G-d willing, of a fetus in utero with a heartbeat! You do not need to drink a large amount of water to fill the bladder before the exam. An internal ultrasound (vaginal) is not dangerous, but usually not necessary, except in instances of vaginal bleeding before 6 weeks gestation.
- Blood tests and urinalysis will be done after a positive ultrasound up until week 12. The standard tests consist of:
- Blood type & Rh factor **
- CBC – complete blood count which will check for anemia
- Rubella titer – immunity to German Measles**
- Fasting blood Glucose
- Viral Infections such as: CMV, Hepatitis B, VDRL(transmitted diseases,) Varicella (chicken pox)
- Urinalysis – a sterile culture and general analysis.
These tests will be carried out in a branch of your HMO that offers laboratory services. You usually do not have to make an appointment, but you do need to arrive between the hours of 07:45 and 09:15 with your referral and magnetic card. This first trimester blood test requires you to be fasting from midnight, though you may drink water. (** Only in the first pregnancy these blood tests are done).
Second Trimester (13-27 weeks):
- Prenatal care in Israel includes an ultrasound which will be done between weeks 20 -24. This second trimester ultrasound is referred to as a detailed ultrasound as it is more in-depth than a standard ultrasound in that the fetus is viewed from head to toe and all of his or her major organ systems are viewed and measured. Sometimes if an anomaly is discovered, a woman will be followed more closely for potential complications, while sometimes life-saving interventions can be carried out during the pregnancy (in-utero in some cases), or immediate special care will be provided following delivery. Most of the time, a couple leaves the ultrasound room with great 3-D pictures and smiles on their faces! It is recommended to book this appointment at least 6 weeks in advance.
- The second set of blood tests and urinalysis will be done around week 24. You do not need to fast. On the contrary, you need to eat breakfast, then go to the clinic and drink a concoction of 50 grams of sugar solution. You will then wait an hour and have your blood drawn. This is called a glucose tolerance test, and measures a pregnant woman’s ability to process sugar and to test for gestational diabetes. Additionally, the blood tests will check her hemoglobin level (iron) which usually goes down as the pregnancy progresses and if she is Rh negative, her anti-D antibodies (coombs) will be tested as well. [If you are Rh negative and your husband’s blood type is positive, then at week 28 you will receive an anti-D shot to prevent an accumulation of anti-D antibodies which could harm your unborn baby] A repeat urine culture will also be done.
Third Trimester 28 weeks-delivery:
- Ultrasound at 34-36 weeks gives an estimated weight leading into the 9th month. Additionally, the amniotic fluid level and the baby’s position is also viewed. Occasionally if there is concern that the placenta is aging too rapidly and not providing enough nutrients or blood flow to the fetus, or there is concern that the placenta is not producing adequate amounts of amniotic fluid, a woman may be asked to repeat ultrasounds at more frequent intervals.
- Vaginal culture for GBS at week 36 is done to rule out carrier status of Group Beta Streptococcus. Only 15% of pregnant women test positive for GBS, which does not cause symptoms during pregnancy, but if a woman does not receive antibiotics after her water breaks or before the baby passes through the birth canal, if untreated can sometimes result in serious illness or even death in newborns. If the GBS bacteria showed up in one of the two urine cultures that were previously done, then there is no need to do this culture, as she would already be considered GBS+. No treatment is given during pregnancy, only intravenous antibiotics during active labor. (Each pregnancy a woman is tested anew).
Postdate Care –from due date to 42 weeks
If a woman goes past her estimated due date, she does not return to her doctor, she goes after a day or two to a clinic in her HMO for postdate care. She is usually given a referral for this eventuality (50% of all deliveries) by her doctor at her last prenatal visit in the 9th month.
Postdate checkups are done every 2-3 days and include the following:
- Ultrasound to measure the amniotic fluid level and umbilical cord flow. This is an assessment of placental function which sometimes decreases as the pregnancies advances. The baby’s position and estimated weight will also be noted.
- Fetal monitoring will be done to measure the baby’s heart rate for 15-20 minutes. This is to reassure the medical team and expectant parents that the baby is fine and we can all be a bit more patient until delivery. Since fetal movements are also monitored, you are encouraged to eat and drink before your monitor. If contractions are measured on the monitor, a baby’s well-being will be assessed as well. Monitoring can be done while a woman is sitting, standing, or lying on her side. Lying flat on her back in not recommended. Fetal monitoring may be done during pregnancy on a regular basis if more comprehensive care is needed or on an emergency basis.
About Michal Finkelstein
Michal Finkelstein RN CNM is a registered nurse-midwife practicing in the Jerusalem area for 30 years. She is the director of Yad L’Em, an organization dedicated to helping women before during and after pregnancy. They also provide subsidized emotional counseling and fertility guidance. Michal has co-authored with her husband, Rabbi Baruch Finkelstein, 3 books; B’Sha’ah Tovah- A Jewish Couple’s Guide to Pregnancy & Childbirth, Delivery From Darkness – Prevention, Detection, and Treatment of Postpartum Depression, and The Third Key- The Jewish Couple’s Guide to Fertility. She can be reached at [email protected] or 054-6205544