0:00 [Music] greetings once again our attention here is going to turn to the third trimester visit now as always I want to preface this but particularly here that this is for medical educational purposes only I know that there are a lot of people that watch my videos that are patients that are trying to self- diagnose and while I believe it's always important for patients to be well educated um this is never all the information that I give is never to substitute the advice from your
0:45 own physician uh so uh please take this with a grain of salt bearing that in mind okay so as all these trimesters we've been talking about there's generally more than one visit visits should be monthly up until 28 weeks then they should be bonly until 36 weeks and then weekly after 36 weeks so uh during all three trimesters there's going to be more than one visit uh so I just put visit in the singular here but bear in mind of course that there are going to be more than one visit uh during pregnancy during each trimester okay so this is sort of an overview of all the things that are done don't memorize this uh this is just a what I found in an OBGYN textbook uh but
1:33 these are uh some of the things that are done and when they should be done according to these authors we'll go over the purpose of the visits during the third trimester we'll talk about some of the labs that are done uh some different ones here that we don't see elsewhere and then I do want to talk in some detail about the gdm testing uh because this is more of a battery of tests rather than a single test and then some of the common events and uh patient education we're not going to talk about uh the management of any of these things should we diagnose them so should we diagnose uh gestational diabetes how we manage that we're not going to talk about that here we're going to uh we're going to discuss that in a future talk uh because this is uh
2:21 for our purposes here we're talking about normal pregnancy okay so the this whole trimester system is really uh it's not important as far as what's happening during the pregnancy so there's nothing magical that happens between the first and second trimester uh once you hit the second trimester there's nothing going on that really delineates the fact that okay now we're in a new a new trimester this is just a way of is really just a means of nomenclature it's completely arbitrary and some people when they Define trimesters they will take okay it's a 40 pregnancy is typically a 40we event normal delivery happens
3:07 around 40 weeks so we're going to divide 40 by three and we'll round that off to 13 weeks per trimester um so we go from 0 to 13 uh 14 to 26 and 27 to 40 giving that extra week to the third trimester others will say well pregnancy can last up to 42 weeks and so we'll divide into 14s it really doesn't matter the way you do it okay so you'll see some sources saying it starts at 26 others you'll see it saying it starts at 28 doesn't really matter okay it really doesn't matter um for the most part the same weeks are going to fall into the trimesters regardless of what method you use so for our purposes the third
3:52 trimester of pregnancy extends from the beginning of the 28th week until the end of pregnancy because at this point the fetus is viable at at 28 weeks and even before that the tests during the third trimester are mainly focused on safeguarding the mother and the fetus's health and preventing any foreseeable complications namely those complications which can arise out of gestational diabetes complications that can arise out of being colonized by Group B strep that's what we're mostly looking at during the third trimester screens so the purpose of the third trimester visits are to monitor fetal growth remember that the fetus is growing
4:38 faster than ever during the third trimester uh and by faster than ever I don't really mean rate so much as I mean uh the raw weight that they are growing so as far as in terms of ounces they're growing faster than ever during the third trimester we also want to ma monitor the fetus's position this becomes important as we get into the final weeks of the pregnancy the fetus is much less likely to move around and change positions the later you get in the pregnancy just because of uh of size constraints and then also the fetus's well-being so as far as well-being we're talking about fetal heart tones you can start monitoring fetal heart tones at 10 weeks you can use a Doppler uh and you will really do that at every visit it doesn't tell us a whole lot provided
5:25 that uh the the fetal heart rate is normal other than that it doesn't really tell us much uh you can measure the funel height now you aren't really going to get a whole lot of information until you hit around 16 weeks and even then measuring the fundle height doesn't tell you a whole lot if it's off by a centimeter uh in either direction it doesn't really it's not really informative uh so we're looking really here for major discrepancies in the fundo height at about 16 weeks starting at 16 weeks the funo height should be in centim approximately the same as her number of weeks gation uh starting at 36 weeks we start to do Leupold Maneuvers these aren't
6:12 done as much as they used to be because we do ultrasounds all the time but the Leopold Maneuvers historically have helped us determine what the fetal lie is so is is the fetus breach or is it in a spalc presentation and then there's some Advanced tests that are done more commonly now but they are still not routine tests and they probably will never be routine tests but they are done frequently because there are a lot of pregnancies that have complications uh so non-stress test is something that you'll see done a lot and then the biophysical profile and the non-stress test is actually part of the biophysical profile so the biophysical profile is really just a more elaborate uh prenatal
6:57 test we also monitor for maternal complications so during the third trimester and towards the end of the second trimester one of the big complications is gestational hypertension and namely preeclampsia during the third trimester the maternal blood pressure should never exceed 120 over 80 and we're here we're talking about a resting blood pressure it should not go above 120 over 80 remember 120 over 80 is perfectly normal in non-pregnant people and you can even go higher than that uh up to 139 systolic resting blood pressure would be considered in in the normal realm in the pregnant woman if it's above 120 over 80 it raises a red flag um now if it's
7:43 significantly elevated and here we're talking about systolic pressure over 140 or diastolic pressure over 90 this is suggestive of preclampsia and we would really need to get this twice uh over a course of greater than four hours in order to to really Point towards preeclampsia uh but if the blood pressure is elevated that is highly suggestive of preclampsia and this is one of the more common complications of pregnancy uh after 20 weeks gestational diabetes is another complication particularly here in the US where mothers have a lot of risk factors for gestational diabetes in the US mothers tend to be a little bit older when they're pregnant compared to in
8:30 lesser developed countries uh they also tend to be more overweight than in other countries in general because we are a fat country uh so technically we only need to do screens on women who have a risk factor for gestational diabetes but some 90% of women who are pregnant in this country have risk factors so we just do diabetes screens for everybody uh and we do this at about 24 to 28 weeks so this will be part of your routine prenatal testing we also retest for gestational anemia we did that earlier on but we have to do it again at the beginning of the third
9:16 trimester and the reason for that is because as the pregnancy progresses the fetal demand for iron increases and so if a woman was sort of borderline gestational anemia but wasn't anemic as she progresses later on into the pregnancy she may become anemic uh in which case we would need to further her supplementation of iron we also detect issues that may alter the management of Labor and Delivery one of the big things here is Group B strep culture screening and that is done at 36 weeks now earlier on we did your analysis and culture and if that culture ever came back positive for Group B strep then we consider her colonized
10:03 with Group B strep and we really don't need to do uh this 36 we GBS culture because we consider her already colonized and we're going to treat her uh with Penicillin during labor and delivery uh but if her urine test did not come back if the the urine culture did not come back positive for Group B strep then here we're going to get a uh we're gonna get swabs of her lower vagina and perianal area and and then see if that comes back positive so this is not necessary if her urine culture came back positive for Group B strep otherwise we get the swab of the lower vagina perianal area and uh and if that
10:49 comes back positive then we will also treat her for Group B stru colonization and that is done that treatment is not done uh once it comes back positive that treatment is administered during labor and then in certain high-risk patients we will repeat that STD screening uh get uh garia chlamidia uh syphilis HIV you can do all that again if it's a high-risk patient namely patients who are uh very sexually active Etc okay so this is how we do fetal heart tone like I said you can start doing this at about 10 weeks which you'll be able to
11:34 uh hear the fetal heart tones with this Doppler device all you do is you take a little bit of jelly place it on the bottom of the transducer and put it right around her lower umico area and um and then you just kind of uh manipulate kind of turn the transducer in place uh and eventually you should hear fetal heart tones very important to to differentiate between the mother's heart tones uh and the fetal heart tones they'll sound pretty similar but the mother's heart tones should be much slower fetal heart tones will run between 110 and 150 if Mom is resting on the bed here she shouldn't be that high she should probably be 60 70 80 uh so
12:20 that will help you just knowing the rate difference another tip for using these uh these transducers don't move it around mom's belly that's not really going to help you all you need to do is place it right in the middle and just kind of turn it in place okay so just you can point it in different directions but don't move it around mom's belly because you're not going to get a whole lot out of that you're just going to wind up with mom's belly full of jelly uh so just move it around in place and eventually you should hit the direction where the the fetal heart is in alignment with the uh with the ultrasound waves that pick up the heart tones okay so just a little tip there the non-stress test is done in
13:05 certain indications in which there are complications that arise during the pregnancy in which we want to uh really make sure that uh baby is doing okay and so in this instance uh what you do is you place uh one transducer which measures mom's contractions uh and then another transducer which measures uh her um um which measures baby's uh heart rate and so uh you may not get contractions uh but what we're really measuring is the heart rate and we want to see if there is any correlation between the baby's heart rate and any contractions that are present so this is an example of a non-stress test and like I said this is not part of routine care but this is
13:52 done in many instances uh when there are any kind of complications that might arise so for instance if she has gestational diabetes or if she has preclampsia we'll do these non-stress tests to make sure baby is doing okay um and so none of these really look like sustained contractions here uh but what we want to look for is accelerations okay so non-stress test we're looking for accelerations and something is considered an acceleration if the fetal heart rate increases by at least 15 beats per minute for more than 15 seconds so we consider that we call that 15 by 15 uh and so we should see more than two
14:40 accelerations over a period of 20 minutes and that is considered a reassuring non-stress test okay so here we see two accelerations okay so the fetal uh the fetal heart rate draw a baseline we'd say it's probably right around 130 or thereabouts and here you see an acceleration going up to about 155 we'll say here and so that is definitely an acceleration of more than 15 beats per minute and as far as time it lasts about a minute okay so definitely an acceleration here and then you see another one here there should be two or more in a period of 20 minutes okay so what are the labs that
15:27 we do well we want to get a urine analysis and this is still recommended there are some organizations authors that say that it's really not important to get your analysis anymore uh but what we're looking for here is glycosuria which is a weak indicator of possible gestational diabetes and protein area which uh used to be a uh a criteria of preeclampsia but is not anymore but some consider it a weak indic of preeclampsia so this is done at each visits still but you may run into some OBG that don't do this anymore we get a CBC here we're looking primarily for gestational anemia and as
16:13 I said because of the increasing fetal iron demand maternal anemia May develop during the third trimester uh a hemoglobin below 10 is considered anemia and then this is of course more more than likely an iron deficiency anemia you can if you want follow it up with iron studies but a lot of people just presume it's iron deficiency anemia and they'll treat it with iron supplementation it does bear uh indicating here that iron supplementation one of the side effects from it is constipation and constipation is something that happens for many reasons during pregnancy uh partially because you've got a big uterus pressing up against the bowels um and there's all sorts of I
17:00 mean that's just one of the more benign things that happens during pregnancy but iron supplementation itself uh can cause constipation so keep that in mind uh the oral glucose tolerance tests which are our screening test and uh the other is a confirmatory test for gestation of diabetes this is done 24 to 28 weeks we'll talk about this in a little bit greater detail later on uh the atypical antibody test this is only done for patients who Rh negative but what we're looking for is the presence of atypical antibodies if she is atypical antibody negative here we're talking about the anti-d antibodies then we give her rogam at 28 weeks if she's atypical antibody
17:46 positive then we don't give her rogam why because it's not going to do anything rogam prevents you from making atypical antibodies um it doesn't do anything if they're already there so if she's Rh negative we get the atypical antibody test at 28 weeks if she is atypical antibody test negative if she doesn't have the atypical antibodies then we give her rogam to prevent her from making antibodies if she's atypical antibody positive then we keep that in mind because there's a possibility of complications arising during this pregnancy and then GBS as mentioned we get vaginal and rectal samples uh sort
18:32 of swabbing around the anus and then the lower vagina and then that is taken and cultured uh if she's positive for GBS then we give her uh five million units of IV penisy and G during labor starting off and then after that every 4 hours until delivery we will give her uh about two million units of penicillin gep so that is done as prophylaxis uh why do we do this because occasionally uh that groupy strep that is in the vaginal tract can get passed on to the neonate and in rare instances but enough to where it's concerning uh
19:20 that baby can then become colonized with the Group B strep and then in some of those instances you can get uh you can get fetal sepsis and GBS pneumonia and so we want to prevent those cases even though they're rare we want to prevent those cases from happening and so any mother who is GBS positive we give her penicillin during labor if she's penicillin allergic you can use clinty or aryin but penicillin is the uh is the drug of choice and I will make videos later on to talk about these in Greater detail I'm just talking about here why we're doing these things okay uh so the
20:06 gestational diabetes testing we get these uh oral glucose tolerance tests and the one that we give to every woman no matter what is the 1 hour 50 g oral glucose tolerance test so this is a screening test and this test alone will not diagnose gestational diabetes okay so this is uh just this liquid that is given to the patient and they drink it there's no need to fast beforehand they drink this liquid and then after 1 hour we will then measure her blood glucose if it's below 140 then that is completely normal and there is no need to do anything else if it's above 140 then we need to do further
20:52 testing okay so if it is above 140 then what we're going to get on her is a fast fting blood glucose and then also a 3-hour 100 G oral glucose tolerance test and this is done if we have a positive screening test and that screening test is the 1 hour 50 gam test okay so first we do an overnight fast and if her fasting blood uh glucose comes back at more than 125 milligrams per deciliter then we consider her to have overt diabetes not just gestational diabetes but overt diabetes uh for our purposes and there's no need to proceed any further we're going to treat her as though she has
21:39 diabetes if it is below 124 124 or below uh then we do this 3-hour 100 G oral glucose tolerance test okay so you can have gestational diabetes but have a normal fasting blood glucose so the 3H hour 100 G oral glucose tolerance test is really very similar to the 1 hour 50 g uh it's just takes a little bit longer so you give this again this oral bolus of of glucose uh which is in sort of a drink a lot of mothers will tell you that this tastes terrible but they drink this uh this bolus and then what you'll do is you'll measure her blood glucose
22:26 at 1 hour after Administration two hours after Administration and 3 hours after Administration and in order to diagnose gational diabetes you need to have abnormal values on two or three of these measurements okay so you have three measurements one at 1 hours one at two hours one at 3 hours but if you just have an abnormal measurement at one of those uh at one of those points it's not diagnostic you have to have it at two or three uh of of these points so abnormal is considered at 1 hour more than 180 at 2 hours more than 155 or at 3 hours more than
23:13 140 so if only one result is abnormal the diagnosis is not gestational diabetes rather it is uh an impaired glucose tolerance and we do not treat that uh like we do gestational diabetes but if you have two or more abnormal points here then we're going to consider that gestational diabetes and their first line of treatment is uh diet and uh appropriate exercise and home glucose monitoring okay and we will talk about that again at a later uh lecture so some of the common events that occur during the third trimester uh during the last several weeks of pregnancy the fetus will move
23:59 into its presenting position which we hope is vertex okay we want a non breach delivery uh and that can be detected either via ultrasound or traditionally via the Leopold Maneuvers and I will talk about that just uh so you have an idea of what that is uh because the name doesn't really tell you much but the Leopold Maneuvers are used to determine the fetal light ultrasound can be done at 35 to 36 weeks to confirm the position and if you have a breach position at 37 to 38 weeks then you can do external spalc version I am not going to talk about that uh here because uh that really goes beyond uh
24:44 the scope of normal prenatal management around 36 to 40 weeks the fetal head will descend into the pelvis hopefully provided we don't have a breach uh lie and and that is caused uh or that is called lightning it causes this phenomenon of what we call lightning and the reason we call it lightning is because the mother will be able to breathe easier it feels lighter why does it feel lighter because the baby's head moves down and so does the rest of the baby's body and because it moves down it's not pushing on the diaphragm as much and so because you don't have all that pressure on the diaphragm the mom is more easily able to
25:32 uh expand her lungs and so it's easier for her to breathe the problem though is that as the baby's head moves down you have more compression on the bladder and so you're going to have some increased urinary frequency you can also get some pelvic discomfort uh genital area discomfort because now the baby's head is so much closer to the uh cervical area and the pubic bones um and so um you can get some pelvic discomfort during this time uh so that's the expense but the mom will often describe this as a positive thing because it's easier for her to breathe even though she does have to go to the bathroom a little bit more some mild cramping some mild lower extremity edema and as mentioned increased urinary
26:19 frequency are all normal events during the third trimester a lot of times we get worked up if we see edema no need most of the edema most women will have some edema during pregnancy most of this edema is going to be coming from the fact that the the uterus the gravid uterus is compressing the uh the the vein uh and so because you have that inferior vnea uh being compressed you're going to have a little bit of back flow in the veins and so those hydrostatic forces are going to push fluid into the lower extremities now if you see upper extremity edema or facial edema that might be a little bit more concerning so some mild lower extremity edema is
27:07 nothing to get worked up about if it's in the setting of hypertension yeah maybe be a little bit more worried but uh just isolated mild lower extremity edema totally normal some mild cramping also normal uh you may have Brax and Hicks contractions uh during this time but uh just mild cramping uh that's not sharp or throbbing in nature just a little bit of discomfort totally normal complications during the third trimester there's a lot okay so you can have premature rupture of membranes that can be pre-term or it can be uh during the term period after 36 37 weeks pre-term Labor and Delivery for
27:53 various reasons abruptio placenta this is painful trimester bleeding okay abruption of the placenta placenta Privia and Vasa Privia placenta Privia being more common this is going to be painless vaginal bleeding painless third trimester vaginal bleeding Vasa Privia is also going to be painless bleeding um the difference here not only is their mechanism but Vasa Privia if you get bleeding from Vasa Privia it's very ominous for the fetus because this is this is uh severe bleeding that's coming straight from the umbilical cord so Vasa Privia is is is always going to be associated with some degree of fetal
28:40 distress placenta Privia you can get a little bit of mild bleeding from that really not so much associated with uh fetal distress unless it's severe preclampsia we already talked about that that's one of the hypertensive disorders of pregnancy uh quite common maternal complications uh include uh UTI gestational anemia and gestational diabetes I meant to put these as subn notes to the maternal complications but anyway UTI much more common during pregnancy than uh non- pregancy and the reason for this is because you have dilation of the URS uh you have some degree of urinary stasis uh UTI should always be treated during pregnancy um and you have to bear in mind that if you
29:26 don't treat them many of them can lead to pylon nephritis and that is a mess so uh UTI keep in mind uh this is going to occur with greater frequency during pregnancy and the further along you get in pregnancy the more common UTI becomes and then we already talked about gestational anemia and gestational diabetes and not only are these do these have effect on the mother but can also have an effect on baby particularly gestational diabetes you can get macrosomia um and then there's also uh supposed long-term problems for the baby can be associated with uh with lower IQ later in life and it can also be associated with a predilection for obesity later in life
30:12 too now these are the Leopold Maneuvers uh so this is the traditional way of assessing the fetal lie uh the first maneuver is called the fundle grip and what you're doing here is palpating the upper abdomen with both hands and you're using the palms of your hands and fingers and what you're feeling for is what's on the upper part of the uterus uh so what you should feel is the baby's butttocks you should not feel a head if the head is up here then you have a breach presentation or at least the fetus is in breach position at that point uh so you're palpating uh with your hands and if you feel something hard or round hard and round then what you're probably feeling is the head and you try to move it around and if it moves independent of the trunk then that
30:59 is certainly a head uh if you feel bony irregular masses that's probably shoulders uh the buttocks should be soft and symmetric okay so you shouldn't feel anything hard up here the second maneuver here is uh known as the umbilical grip and what you're feeling for here is the fetal spine so you take your hands uh you hold one hand in place and you p at with the opposite hand and you're feeling for the fetal spine which you can imagine what that feels like um and the fetal spine could be on either side so it really just depends on what direction or what what side the baby's lying on so that's why you do it with both hands and the spine should just be
31:44 this sort of long uh straight uh maybe slightly curved uh projection of uh of bony prominences the Third maneuver is called the first pelvic grip so here you're taking one hand you're feeling right above the pubic symphysis uh using your thumbs and fingers and uh that should validate your first maneuver so here you should feel head you should feel some uh you should feel a hard prominence should be somewhat symmetric um rounded off and so here you're feeling for the head and then the fourth maneuver is called the second pelvic grip and here you're attempting to locate the fetal brow so what you're going to do here is you're
32:30 going to turn around the opposite side here so you're going to be facing her feet uh and you're going to stabilize the the spine with one hand and then move your hand down her uterus on the opposite side until you hit some resistance and that is typically where the brow is okay so you're getting an idea of how the fetus is lying leapold Maneuvers a lot have been really just replaced with ultrasound because it's so much easier uh to see where the baby is laying than these uh this leaph hold maneuver which really takes a lot of training uh to get really good at it okay so these aren't done quite so much but experienced OBG y will will still use this from time to
33:16 time so patient education we want to make sure that she's up to date on her vaccines uh we always will give the Tdap vaccine in the third trimester regardless of her previous vaccinations because we will uh by giving the vaccine we cause another exposure and that exposure will cause mom to make antibodies and those antibodies can then be passed to baby uh so we always give the Tdap vaccine regardless of when the last time was that she received it the influenza vaccine is given if it hasn't been given already uh if it is the season so if it's June we're not going to give her the influenza vaccine if it's November
34:01 we will Hepatitis B if there's no prior immunity so remember back during the first trimester we gave the or we did that Hepatitis B panel if she doesn't have any immunity to Hepatitis B then we give the vaccine at that point and you could probably do it earlier you want to discuss the signs and symptoms of Labor with her so a lot of women will know what labor is uh but but this is particularly uh important for the pag gravidas uh so spontaneous rupture of membranes also known as my water broke or if there's contractions every 5 to 8 minutes for an hour uh discuss symptoms requiring a prompt evaluation I.E when do I come in
34:50 well if there's signs of labor if there's rupture of membranes which is also kind of a sign of labor if there's vaginal bleed eting that can be a sign of placenta Privia it can uh it can also be a sign of Vasa Privia it can also be a sign of abruptio placenta uh so that is an indication to come in if there's worsening edema if there's headaches or visual changes this can all be Associated is all associated with preclampsia and then the peripartum and postpartum considerations so we want to know where does she plan on delivering does she have a particular Hospital in mind uh now would be a good time to do the tour of the hospital of the labor and delivery Ward so she has an idea of
35:35 what's going to happen uh how is she going to deliver is it going to be a vaginal delivery is it going to be a C-section remember that if she has had more than one C-section then we're always going to do C-sections thereafter if she's had one C-section in the past just one then you can do a vaginal delivery uh but there are some caveats with that that's called a vac vaginal birth after c-section U now the one exception to this is if her prior C-section was not the low transverse C-sections that we do traditionally these days but was the uh the up and down uh
36:21 incision then in that case uh even if she's only had one if she's had the that vertical incision uh in that case we always have to do C-sections after that that's because of the risk of uterine rupture so in this day and age we do that fan and steel incision where it's the low transverse cutting from side to side and that is conducive with a VB back you can do a v-back after that as long as you've only done that C-section once okay so hopefully I made that clear if you have any questions write me note below there are some people now that are saying that you can do vacks after two C-sections but that is not standard and
37:08 certainly ACOG has not validated that but that has been thrown around in recent years you want to know what her desire is for analgesia uh and anesthesia wishes so does she want to have an epidural uh does she just want a spinal uh does she want to have nitrous what does she want how much anesthesia does she want some mothers don't want any they want to experience the quote unquote natural childbirth others are like give me whatever whatever you can give me that doesn't hurt the baby because I don't want to feel any pain that's probably not going to happen but there's going to be different different preferences okay so you want to discuss that with her you also want to discuss breastfeeding with her you don't need to
37:54 go into too great of detail because while she's in the hospital you can if does want to breastfeed you can uh set her up with a lactation consultant uh but one of the things that we have found helps with breastfeeding is skin-to-skin contact after delivery and so that is something to keep in mind if she does desire to breastfeed circumcision if it's a boy and then postpartum contraception uh you I don't think I've talked about this yet but uh there is uh some contracep cve uh value to breastfeeding actually I did talk about this in the Gynecology section uh there is some contraceptive value to breastfeeding uh but it's not
38:39 perfect so um you want to discuss that with her that it doesn't take long after the pregnancy and she will be fertile again we call those Irish twins and you have uh you have one baby and then you get pregnant right away and uh I have a pair of uncles that are only a year or two apart okay
