Third Trimester

Adbhut Matrutva

The third trimester algorithm

Dr S.SHANTHA KUMARI

M.D. D.N.B. FICOG FRCPI (Ireland)

Consultant –Yashoda Hospitals, Hyderabad

PROFESSOR OBGYN

CHAIRPERSON ICOG 2018

CONSULTANT YASHODA HOSPITAL

ICOG SECRETARY 2015 -2017 (Indian College of Obstetricians & Gynaecologists)

Member FIGO working Group on Violence Against Women

VICE PRESIDENT FOGSI 2013

ICOG GOVERNING COUNCIL MEMBER

IAGE MANAGING COMMITTEE MEMBER

NATIONAL CORRESPONDING EDITOR FOR JOGI

ORGANIZING SECRETARY AICOG 2011CHAIRPERSON MNNRRC 2008

Third trimester of pregnancy

Week 28 – labour/delivery

Care During Pregnancy

"Algorithmic approach": third trimester

Proceed step by step in a logical manner to continue antenatal care from second trimester till labour/delivery

Step 1 : taking stock

Review notes till the second trimester
Check routine investigations check list
Review risk factors
Plan further antenatal visits and tests
Plan further care …..

WHO Guideline on Antenatal Care (2016)

Overview

Reproductive Health and Research (RHR)

Nutrition for Health and Development (NHD)

Maternal, Newborn, Child and Adolescent Health (MCA)

Antenatal care is critical

Through timely and appropriate evidence-based actions related to health promotion, disease prevention, screening, and treatment

Reduces complications from pregnancy and childbirth
Reduces stillbirths and perinatal deaths

Women’s views

Women want a

Positive Pregnancy Experience

from ANC

A healthy pregnancy for mother and baby (including preventing or treating risks, illness and death)
Physical and sociocultural normality during pregnancy
Effective transition to positive labour and birth
Positive motherhood (including maternal self-esteem, competence and autonomy)

Medical care; relevant and timely information; emotional support and advice

2016 WHO ANC model

Contact versus visit

The guideline uses the term 'contact' - it implies an active connection between a pregnant woman and a health care provider that is not implicit with the word 'visit'.
- – quality care including medical care, support and timely and relevant information
In terms of the operationalization of this recommendation, 'contact' can take place at the facility or at community level
- – be adapted to local context through health facilities or community outreach services
'Contact' helps to facilitate context-specific recommendations
- – Interventions (such as malaria, tuberculosis)
- – Health system (such as task shifting)

IMMUNIZATION IN PREGNANCY

ROUTINE VACCINES: SAFE DURING PREGNANCY

Tetanus
Influenza
Hepatitis B
Meningococcal
Rabies

Special considerations ; pneumococcal vaccine, typhoid, cholera, hepatitis A, Yellow fever, Japanese encephalitis, polio.

CONTRAINDICATED- Live attenuated vaccines Measles, mumps, Rubella, Varicella, BCG Oral polio

Influenza

Killed virus preparation with annually adjusted antigenic makeup.
Current Canadian recommendations advocate universal immunization of pregnant women against influenza in second or third trimester of pregnancy.
Another reason for immunization in pregnancy is the protection of the newborn after birth, which can be accomplished with passive immunity (transfer of maternal antibodies). Further, the most common way for infants to acquire influenza is from household contacts, so immunization of the mother can prevent her from acquiring influenza and potentially passing it on to her child.
Trivalent inactivated influenza vaccine (TIV),live attenuated influenza vaccine (LAIV),recombinant quadrivalent vaccines are available in India.
TIV is annual, single IM dose of 0.5 ml also known as flu shot(H1N1,H3N2,influenza B)
LAIV is administered by the intranasal route is approved for use in adults upto 50 years of age. Evidence recommends people at high risk for influenza related complication.
Recombinant quadrivalent vaccine is given, intradermal 0.5ml single dose. saftey in pregnancy is under trial.

Committee Opinion

Obstetric care providers should administer the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine to all pregnant patients during each pregnancy, as early in the 27–36-weeks-of-gestation window as possible.
Pregnant women should be counseled that the administration of the Tdap vaccine during each pregnancy is safe and important to make sure that each newborn receives the highest possible protection against pertussis at birth.
Obstetrician–gynecologists are encouraged to stock and administer the Tdap vaccine in their offices.
Partners, family members, and infant caregivers should be offered the Tdap vaccine if they have not previously been vaccinated. Ideally, all family members should be vaccinated at least 2 weeks before coming in contact with the newborn.
If not administered during pregnancy, the Tdap vaccine should be given immediately postpartum if the woman has never received a prior dose of Tdap as an adolescent, adult, or during a previous pregnancy.
There are certain circumstances in which it is appropriate to administer the Tdap vaccine outside of the 27–36-weeks-of-gestation window. For example, in cases of wound management, a pertussis outbreak, or other extenuating circumstances, the need for protection from infection supercedes the benefit of administering the vaccine during the 27–36-weeks-of-gestation window.
If a pregnant woman is vaccinated early in her pregnancy (ie, before 27–36 weeks of gestation), she does not need to be vaccinated again during 27–36 weeks of gestation.

Third trimester checklist

What has been done

Booking tests
ANC notes
Screening tests for anemia, infections, pre eclampsia, GDM and fetal anomalies/aneuploidies
TT immunisation
Familiarise with important past history / familial health issues

Plan for What needs to be done

Third trimester algorithm : By 28 weeks

Measure Symphisio fundal height
Hemoglobin – 28wks – second check for anemia
Red cell antibodies
Indirect Coomb’s test for the Rh negative
OGTT – second check for GDM
BP measurements, proteinuria
Offer opportunity to ask questions and clarify doubts

Nutrition in third trimester

Fresh fruits /vegetables : "5-a-day"
Carbohydrates – whole grain varieties at every meal
Low fat dairy products :2-3 times a day
Proteins: varieties of protein rich foods: 2 times a day

My Pregnancy Plate

DIET IN PREGNANCY

Yoga in third trimester

Relieves Backache
Helps in increasing physical wellness – posture and balance
Increases positive endorphins – good mood
Meeting people
Making friends
Peer groups
Better diet habits

Exercises During Pregnancy

COSMETIC CARE

Hyperpigmentation
Frontoparietal thinning of hair due to increase in androgens
Telogen effluvium- postpartum, diffuse shedding
Striae : abdomen, breats,thighs (mechanical stretching and increased estrogen, relaxin, adrenocortical hormones)

CLEANLINESS

Personal Hygiene prevents acquiring infection and also from transmittibg to the baby

Wash your hands with soap and water before every meal and after attending toilet.

Clip your nails regularly

Have a bath daily

Dental hygiene

PREPARING FOR DELIVERY

STAGES OF LABOUR

I Stage : Early labor and active labor. Early contractions that are irregular and last less than a minute.(last from a few hours to days). active contractions that are regular and last about a minute. Once active contractions begin - need to head to a hospital or birthing center.
II Stage: lasts through the actual birth. During the second stage,cervix is completely dilated and baby travels down and out of the birth canal.
III Stage: occurs after baby is born. Contractions continue until the placenta is delivered out of birth canal.

Third trimester algorithm : 32-34 weeks

Measure symphysio fundal height
Plot on gravidogram
Check BP – proteinuria
Fetal growth scan as indicated
Placental localisation scan as indicated(based on earlier suspicion of previa/accrete etc)
Review earlier tests and discuss further care plan with the pregnant woman – allow her to ask questions and clarify doubts
Identify women with need for additional support

General discomfort

Physically challenging to handle the increased "weight of pregnancy"
Sleeplessness
Irritability
Tender loving care
Positive motivation by spouse, peers and family

Third trimester algorithm : 36-40 weeks

Measure symphysio fundal height
Plot on gravidogram
Check BP – proteinuria
Check fetal position
Consider ECV for breech presentation
Refer the women with placenta previa/accrete to appropriate centres
Discuss further care plan with the pregnant woman – allow her to ask questions and clarify doubts

Third trimester algorithm : 40 weeks - delivery

Measure symphysio fundal height
Plot on gravidogram
Check BP – proteinuria
Closer antenatal surveillance
Refer to district hospital if needed
Offer induction of labour
Discuss further care plan with the pregnant woman – allow her to ask questions and clarify doubts

FETAL KICK COUNT

MATERNAL PERCEPTION OF DECREASED FETAL COUNT MAY BE A RED FLAG SIGN FOR IMPENDING FETAL DISTRESS.

Fetal kick are appreciated for the first time at around 18-20weeks.

Fetal kick count is significant after 28weeks.

The DFMC requires pregnant women to begin a fetal movement count at a selected time each day, count 10 movements and record the elapsed time from the first to the tenth movement. Findings which would indicate possible danger to the fetus, and which should be reported immediately, include less than 10 movements in 12 hours; no perception of movement in an eight- hour period; a change in the usual pattern of fetal movement; or a sudden increase in violent fetal movements followed by complete cessation of movement.

kick count log

Danger Signs During pregnancy

WHAT ARE THE DANGER SIGNALS?

IF ANY OF THE FOLLOWING OCCUR – SEEK HELP IMMEDITALEY AND REACH HOSPITAL TO PRESERVE YOUR HRALTH AND LIFE

Severe abdominal pains or cramps
Generalised weakness, easy fatiguability and breathlessness
Vaginal bleeding
Convulsions
Excessive swelling of the feet,
blurring of vision,
severe and persistent headache
Decreased urine output
Fever
Sudden gush of fluid from the vagina

Danger Signs During pregnancy

Varginal Bleeding

Fits

Severe Abdominal Pain

Severe Headache

Very Pale

Fever

When to go to Hospital

Regular Contractions with intensity
SROM
Vaginal Bleeding
Changes in Fetal Movement ecpecially a in fetal movement as described in the Daily Fetal Movement Count

Overall wellbeing

Practicing empathy and effective listening as a health care provider
Address emotional wellbeing issues:
- Stop Worrying
- Communicating feelings and needs to others
- Partner compatibility

Working women : third trimester

Planning maternity leave
Traffic safety issues if driving to work
Emergency contact persons
Back up plan for sudden

GOI initiatives

PREPARING FOR BREAST FEEDING AND POST PARTUM PERIOD

Postpartum Problems Every Mom Should Know About

Caring For Tears Or An Episiotomy Wound

It is normal for vaginal wounds to take a few weeks to heal, but do watch out for signs of infection. If your wound becomes red, hot, or starts oozing pus see your OBGYN right away.

Breast Problems

Apply cold compresses and cabbage leaves on sore breasts, gently massage your breasts or even pump some milk. Lanolin soothes cracked and painful nipples.

Lochia-The 'Mother Of All Periods'

Seek medical help if you pass extremely large clots, bleed so heavily that you saturate a pad or more an hour, or your lochia smells foul.

Diastasis Recti

Wait until your healthcare provider gives you the green light to exercise, usually at the six-week postpartum checkup.

Baby Blues & Postpartum Depression

Did you know that between 70 and 80 percent of postpartum moms experience some mood swings or negative feelings after their baby's birth?

Uterine Problems

The Uterus needs to shrink back to its tiny non-pregnant size after labor and birth, and this might cause painful contractions. Your pelvic floor muscles will have weakened during pregnancy and birth, so it is best to start doing kegel exercises soon after you give birth.

Constipation And Hemorrhoids

Apply cold packs to the area to eqase swelling and pain. Herbal sitz baths combat hemorrhoids and vaginal tears.

BREAST FEEDING

Breastfeeding is one of the most effective ways to ensure child health and survival.
If every child was breastfed within an hour of birth, given only breast milk for their first six months of life, and continued breastfeeding up to the age of two years, about 800,000 child lives would be saved every year.