3rd Trimester- Workup & Algorithms
- 1. Adbhut Matrutva : The third trimester algorithm Dr S.SHANTHA KUMARI M.D. D.N.B. FICOG FRCPI (Ireland) 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
- 2. Dr. S. Shantha Kumari MD. DNB FICOG. FRCPI(Ireland) Consultant –Yashoda Hospitals, Hyderabad Chair person of Medical Nomenclature ,Norms, Research Records committee of FOGSI 2008 - 2010 Organizing Secretary of AICOG 2011 – Hyderabad Vice President FOGSI 2013 ICOG Governing Council Member 2012 -2015 IAGE Managing Committee Member 2013 - 2015 National Corresponding Editor for Journal of Obstetrics & Gynecology of India 2011 - 2013 ICOG Secretary 2015 - 2017 FIGO Working Group on Violence Against Women Member 2015 - 2018 ICOG Chairperson 2018 -2019
- 3. Third trimester of pregnancy: Week 28 – labour/delivery
- 5. “Algorithmic approach”: third trimester Proceed step by step in a logical manner to continue antenatal care from second trimester till labour/delivery
- 6. 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 …..
- 7. 7 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) Geneva, Switzerland
- 8. 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
- 9. 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) Women want a Positive Pregnancy Experience from ANC Women’s views Medical care; relevant and timely information; emotional support and advice Downe S et al, 2016
- 10. 2016 WHO ANC model
- 11. 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)
- 12. IMMUNIZATION IN PREGNANCY • ROUTINE VACCINES: SAFE DURING PREGNANCY o Tetanus o Influenza o Hepatitis B o Meningococcal o 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
- 13. 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.
- 14. • 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.
- 15. 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
- 16. 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
- 17. 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
- 20. 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
- 22. 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)
- 23. 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
- 25. 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.
- 26. 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
- 27. General discomfort • Physically challenging to handle the increased “weight of pregnancy” • Sleeplessness • Irritability • Tender loving care • Positive motivation by spouse, peers and family
- 28. 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
- 29. 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
- 30. 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.
- 33. WHAT ARE THE DANGER SIGNALS? • 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 IF ANY OF THE FOLLOWING OCCUR – SEEK HELP IMMEDITALEY AND REACH HOSPITAL TO PRESERVE YOUR HRALTH AND LIFE
- 36. 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
- 37. Working women : third trimester • Planning maternity leave • Traffic safety issues if driving to work • Emergency contact persons • Back up plan for sudden medical help
- 38. GOI initiatives
- 39. PREPARING FOR BREAST FEEDING AND POST PARTUM PERIOD
- 40. 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. - WHO
- 44. SENSITIZATION AND CONNECTING WITH YOUR CHILD AND DOCTOR • The closeness of the parent-child connection throughout life results from how much parents connect with their babies, right from the beginning.
- 45. Third trimester:MUST DO • Breast feeding techniques • Preparation for labour and birth • Recognition of active labour • Care of newborn • Postnatal self care • Awareness of postnatal depression
- 46. Third trimester of pregnancy: Week 28 – labour/delivery “Algorithmic approach”: third trimester Proceed step by step in a logical manner to continue antenatal care from second trimester till labour/delivery THANK YOU !!