Setting Up Your Care Structure

The foundation for everything else

Who is responsible for your pregnancy, who does what, how to reach them after hours, which tests have deadlines and what to do if your care suddenly changes.

Key points

New York’s patients’ rights regulation gives every hospital patient, including outpatients, the right to know “the name of the medical staff member who has the responsibility for coordinating” their care. Ask in writing: “Which physician is responsible for my prenatal care?”
First-trimester screening with a nuchal translucency scan, an ultrasound that measures fluid at the back of the baby’s neck, happens at about 11 to 14 weeks, and the test for Group B strep, a common bacteria, at 36 to 37 weeks. Put the last possible day of each testing window on your calendar.
The American Medical Association’s Code of Medical Ethics says a physician ending care should give notice “long enough in advance to permit the patient to secure another physician” and help transfer care. If your care is cancelled, ask in writing who covers you until a new practice sees you.

The pieces

1. One named physician

Not a practice, not a team, not a scheduler: a physician who is responsible for your pregnancy, in writing. In my first pregnancy, I asked my specialist what the physician assistant (PA) did. The answer was that the PA would see me first, and that I was one of their “low risk patients.” I had been referred to that practice because of my risk factors. Know who sees you, and who is responsible.

2. Your primary care doctor

Your primary care doctor stays with you before, during and after pregnancy, even when obstetric practices change. I see mine about once a quarter. My primary care doctor has helped with testing and referrals, including telling me, in my second pregnancy, when my window for first-trimester screening was closing, and the practice has a maternity program with resources I can use. Ask yours what they can coordinate during pregnancy, and whether the practice or health system offers maternity resources.

3. OB and maternal-fetal medicine: who leads

If you’re referred to maternal-fetal medicine (MFM), the high-risk specialists, ask how they work with your OB. Does MFM consult and send recommendations back, or take over your care? Who acts on what they recommend?

4. After hours

Know the after-hours number, who answers it and where to go: the exact address and entrance for labor and delivery triage.

5. Your insurer’s nurse case manager

Some insurers offer a nurse case manager, especially in a high-risk pregnancy. A case manager can explain your coverage, help with out-of-network exceptions and sometimes move a stuck referral. I didn’t know to ask until I was desperate, in my second pregnancy. Call the member services number on your insurance card and ask whether you have one.

6. Referrals: who owns each one

For every referral, ask five questions:

Who books it?
What records do they need?
Who sends them?
Who explains the result?
What happens if it’s cancelled?

Two or three days before the visit, have someone call the receiving office to confirm they have the referral, notes and results. When those responsibilities weren’t clear, I ended up doing the follow-up.

7. The testing windows

Prenatal care runs on deadlines. These are the common windows. Your team may adjust them for your pregnancy.

First-trimester screening with nuchal translucency ultrasound: About 11 to 14 weeks (UCSF Health)
Anatomy ultrasound: About 18 to 22 weeks (TRICARE pregnancy schedule)
Glucose screening for gestational diabetes: Usually at 24 to 28 weeks. Your clinician may test earlier for previously unrecognized diabetes based on your risk factors; that is a separate question from routine gestational-diabetes screening.
Tdap vaccine (tetanus, diphtheria and whooping cough): 27 through 36 weeks (Immunize.org)
Group B strep test: 36 to 37 weeks (ACOG guidance, via OBG Management)

In my first pregnancy, I asked in writing: “Can we preschedule those appointments through the remainder of my pregnancy?” When my fetal echocardiogram, an ultrasound of the baby’s heart, was offered on dates later than it needed to be, I had to ask the office to get it in on time. Ask early, and ask for the dates.

8. The care team sheet

One page: each person’s name, role, phone number, portal and what they handle, plus the after-hours line and the triage address and entrance. Give copies to your partner and a backup person. If you’re the one who’s sick, you won’t be looking up numbers. This is a good job to hand to your advocate, whether that’s a partner, doula or family member: they keep it current, not you.

9. The records folder

On your phone and on paper:

Your prenatal flow sheet, the running summary of visits, vitals and labs
Recent lab results and every urine culture
Imaging and ultrasound reports
Operative reports and discharge summaries from any past births
Your current medication and supplement list
Every referral letter and progress note
Your insurer’s case manager’s name and direct number

Send your own records to a new provider instead of waiting for offices to exchange them.

If your care structure suddenly changes

In my second pregnancy, the high-risk practice that had cared for me in my first pregnancy cancelled all my appointments the day before my first scan. No physician contacted me. For weeks, I asked in writing for the name of the physician responsible for my pregnancy. My request went from a scheduler to a coordinator, to patient relations, to my insurer’s case managers and to the hospital’s ethics consult service. No physician answered it. By the time I was nearly 13 weeks, the window for first-trimester screening was closing, and I traveled out of state to an OB who could see me the next day.

I could do that. Most people can’t. If it happens to you, here is what I learned:

A scan is not the same as care, and neither is a referral. An intake call isn’t a practice accepting you. Shared records aren’t a handoff. A new doctor being able to see your chart isn’t the same as a doctor who has read it, agreed to take you on and made a plan.

Say exactly what’s missing, in writing. This is what I wrote:

At this time, I do not have:

an established OB/GYN physician,
an established Maternal Fetal Medicine physician,
or a specified accepting provider overseeing my pregnancy within [the hospital] system.

Then ask, in one sentence, and repeat it. “I am requesting the physician responsible for my prenatal care, and the next steps.”

Ask who covers the gap. If the new practice can’t see you for three weeks, who do you call about a symptom in week two?

Name the window. “This test has to happen by this date. Can you help me get it scheduled?”

Get the transfer in writing. The new practice confirms it has accepted your care, and as of what date. The old practice confirms it sent your records. The new one confirms it reviewed them.

Correct the record the same day. I was told I’d declined an ultrasound I hadn’t declined. I wrote back: “I do want to clarify that I did not decline any appointments.” The scheduler later confirmed it.

If you can’t travel, before a window closes:

Ask your insurer’s nurse case manager whether your plan makes exceptions when no in-network provider can see you in time, and what out-of-network care would cost.
Ask any clinician you already have, such as your primary care doctor, a midwife or a general OB, whether they can order the scan at an imaging center with sonographers certified for nuchal translucency.
Ask what screening options remain if the window does close, so you’re choosing rather than losing.

Know your rights. New York’s regulation also gives you the right to complain without fear of reprisal and to receive a response, in writing if you ask. Most states have similar rules. Search [STATE] hospital patients bill of rights, or ask the hospital’s patient relations office for its own.

Take this back

To discuss with your care team:

Who is my primary clinician for this pregnancy?
If I’m referred to MFM, are you still managing my care, or are they?
Who answers urgent concerns after hours, and what number do I call?
Can we schedule my remaining visits now, and which tests have a deadline?
If my care moves, who is responsible for me until the new practice sees me?

To discuss with your insurer: Do I have a nurse case manager? What’s covered out of network if I can’t get in on time?

To discuss with the people in your life: Do you have my care team sheet? If I can’t make the call, will you?

Don’t wait if

No question about who’s responsible should delay urgent care. For chest pain, trouble breathing, heavy bleeding, a severe headache that won’t go away, or a baby whose movement slows or stops, go to labor and delivery triage or the emergency room. Sort out who’s responsible afterward.

Next in the series: “Managing Conditions, Medications and Test Results”