Third Trimester work up and Algorithms ADBHUT MATRUTVA

1. Third Trimester work up
and
Algorithms DR.PRATIMA
MITTAL

2. GOAL
To ensure the birth of a healthy baby with
minimal risk for the mother.

3. OBJECTIVES
• Continued ONGOING EVALUATION of health status of
mother and fetus
• Anticipation of problems
• Interventions, if possible to prevent morbidity

4. FREQUENCY OF VISITS.
ACOG
RECOMMENDATIONS
• NULLIPAROUS WOMEN
WITH UNCOMPLICATED
PREGNANCIES
(16 VISITS) :-
1. Every 4 weeks tilL 28
weeks
2. Every 2 weeks from 28 -36
weeks
3. Weekly until delivery
• PAROUS WOMEN WITH
UNCOMPLICATED MEDICAL
AND OBSTETRICAL
HISTORIES=less frequently.
• WOMEN WITH PROBLEMS
are seen more frequently,
depending on the nature of
the problems.
NICE GUIDELINES
• 10
appointments
for nulliparous
women
• 7 appointments
for parous
women
• Each visit
should have a
specific
purpose/goal
•Minimum of eight antenatal
visits for all women,
regardless of parity
•One visit in the first trimester
•Two in the second trimester
•Five in the third trimester.
•High risk pregnancies need
additional care
WHO GUIDELINES
2016

6. INITIAL EVALUATION IF
FIRST VISIT IN THIRD
TRIMESTER
• - Medical/Obstetrical history
• - Psychosocial history
• - Correct estimation of period of
gestation.
Examination
General Physical Exam : Resp
/cardiac system
Obstetric Examination
History

7. Standard panel
– Rhesus type and antibody
screen
– Hematocrit or hemoglobin
and mean corpuscular volume
– Rubella immunity and
varicella
– Qualitative assessment of
Urine protein
– Urine culture
– Cervical cancer screening acc
to standard guidelines
– Human immunodeficiency
virus
– Syphilis
– Hepatitis B virus
Selective screening
 Thyroid function
 Type 2 diabetes
 Infection
- Gonorrhea
- Hepatitis C
- Tuberculosis
- Toxoplasmosis
- Bacterial vaginosis
- Trichomonas
vaginalis
- Herpes simplex
virus
- Cytomegalovir
u
- Zika
- Chagas disease
INITIAL EVALUATION
IF FIRST VISIT IN
THIRD TRIMESTER
Laboratory tests

8. FOLLOW-UP VISITS :ONGOING
ASSESSMENTS
• Measurement of blood pressure
• Measurement of weight
• Urine dipstick for protein
• Assess fetal growth =SFH/ultrasound
evaluation for women with risk factors
for IUGR
• Assessment of maternal perception of
fetal activity
• Assessment of significant events since
prior visit, such as recent travel, illness,
stressors, or exposure to infection (eg,
Zika virus) etc.

9. FOLLOW UP VISITS-PERIODIC
ASSESSMENTS
Prenatal screening should be performed
early WITHIN RECOMMENDED INTERVALS
to allow adequate time for:-
• Follow-up of screening tests
• Performance of diagnostic tests
• Counseling about test results
• Discussion of management options,
including termination of pregnancy if
the patient chooses this approach.

10. MANAGEMENT OF PREGNANCY
COMPLICATIONS -RISK APPROACH
• Risk is the possibility of coming to harm
• Vulnerability is the degree to which one
would be adversely impacted by the risk
• Vulnerability is a parameter which we
can influence

12. MANAGEMENT OF COMMON
DISCOMFORTS
- Nausea and vomiting
- Gastroesophageal reflux disease
- Constipation
- Hemorrhoids
- Rhinitis and epistaxis
- Gingivitis
- Difficulty sleeping
- Headache
- Back pain and sciatica
- Leg cramps
- Peripheral edema
- Varicose veins
- Diarrhea
- Urinary frequency and nocturia

13. ASSESSMENT OF FETAL WELL BEING
AT ANC
• Progressive Fundal height growth as per expectation
• Adequate maternal perception of fetal movements
• Ultrasonographic fetal assessment esp for anomalies

14. COUNSELING
Counseling about
•Diet
•Exercise
Rest
•Immunisation
•weight gain
• Alcohol
•Smoking
•Dress
•Personal hygiene
•and warning symptoms

15. A
T
I
E
N
T
E
D
U
C
A
T
I
O
A T I E N T E D U C A T I O N

16. NUTRITION
CALORIE REQUIREMENTS
• 340 and 450 additional kcal/day in the
second and third trimesters,
respectively, for appropriate weight
gain
• Recommended daily allowance (RDA)
for an Indian reference woman ( 20 – 29
yrs, weighing 50 kg)
•
particulars Kcal/d
ay
protein (g/d) fat (g/d)
nonpregn
ant
2200 50 20
pregnant +300 +15 30
lactating +550
+400
+25
+18
45

17. NUTRITION

18. IRON SUPPLEMENTATION
WHO
iron 60mg + folic acid 400μg/day
• supplementation starting in second
trimester & continuing for the rest of
pregnancy & 3 mths postpartum
Anemia Prophylaxis MOHFW INDIA Six
months in pregnancy and six months after
delivery
– Nonanaemic preg women – 100mg
elemental iron & 500μg of FA daily
– Anaemic pregnant women – 200mg
elemental iron & 1 mg FA/day

19. EXERCISE DURING
PREGNANCY
ACOG(2015)
1. A thorough clinical examN mandatory before recommending
an exercise program.
1. In the absence of C/I –regular, moderate intensity physical
activity for 30 min/day recommended
2. Activities with a high risk of falling, abdominal trauma/ scuba
diving (increase fetal risk of decompression sickness) should be
avoided.

20. TRAVEL:AUTOMOBILE-
USE OF SEAT BELTS AND AIR BAGS
• Pregnant women should continue wearing
three-point seat belts during pregnancy.
• The lap belt is placed across the hips and
below the uterus; the shoulder belt goes
between breasts and lateral to the uterus.
• ACOG=pregnant occupants of motor vehicles
wear lap and shoulder seatbelts and should not
turn off air bags

21. SEXUAL INTERCOURSE IN PREGNANCY
• In the absence of pregnancy complications (eg,
vaginal bleeding, ruptured membranes), IT IS
ALLOWED with less frequency and violence.
• Whenever abortion or preterm labour is a threat,
coitus should be avoided.
• Abstinence in the last 4 weeks of pregnancy for
fear of ascending infection may be considered

22. AT EACH VISIT

23. Ix

24. 28 WEEKS

25. 36 WEEKS

26. POINTS CONSIDERED BETWEEN 28-40 WEEKS
• Estimated fetal weight-CLINICAL/USG
• Fetal assessment-APFM AFTER 28 WEEKS
• ECV for breech presentation

27. SIGNS AND SYMPTOMS THAT SHOULD BE
REPORTED TO THE HEALTH CARE PROVIDER
OBSTETRIC
●Vaginal bleeding
●Leakage of fluid per vagina
●Decreased fetal activity
●Signs of preterm labor (eg, low backache; increased
uterine activity compared to previous patterns;
menstrual-like cramps; diarrhea; increased pelvic
pressure; vaginal leaking of clear fluid, spotting or
bleeding, contractions)
●Signs of preeclampsia (eg, headache not responsive
to acetaminophen, visual changes that do not resolve
after a few minutes, persistent right upper quadrant
abdominal pain)
● Signs or symptoms suggestive of a MEDICAL
OR SURGICAL DISORDER

28. BIRTH PLAN=MODE OF DELIVERY
• Cervical scoring
• Pelvic assessment

31. PATIENT EDUCATION REGARDING
POSTPARTUM ISSUES
• Breast feeding

32. PATIENT EDUCATION REGARDING
POSTPARTUM ISSUES
• Postpartum care & complications

33. PATIENT EDUCATION REGARDING
POSTPARTUM ISSUES
• Newborn care

34. PATIENT EDUCATION REGARDING
POSTPARTUM ISSUES
• Postpartum contraception

35. MANAGEMENT OF COMPLICATIONS

36. CONCLUSION
• Comprehensive care
• Risk approach
• Individualize
• IEC
• TLC
• Involve the family