ADBHUT MATRUTVA

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

19. DIET IN PREGNANCY

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 !!