Third Trimester Issues & Considerations

Car crashes can be a cause of death and serious trauma during pregnancy. During the third trimester, moving around or sitting for long periods of time becomes difficult. If you do need to travel, be sure to follow a few car safety tips:

• Limit travelling to a maximum of 6 hours in a day and stop every hour or two and walk around to stretch your legs to keep the blood circulating.
• You can place a pillow or cushion on your seat to make travel more comfortable.
• Always remember to fasten your seat belts so that the lap belt portion rests under your abdomen and the shoulder harness is positioned between your breasts.
• Keep the air bags turned on.
• Wear comfortable clothes; preferably, loose cotton wear.
• Keep a charged mobile phone handy for any emergencies.
• If you are driving, maintain a minimum distance of 10 inches between the steering wheel and the breast bone.

What is cord blood banking?

Cord blood banking is the process of collecting and storing cord blood (blood that remains in the umbilical cord and placenta following birth) in an outside facility for future medical use. This blood is a reservoir of potentially lifesaving cells called stem cells, which can be used as and when required to treat many diseases.

How is it done?

Collection and processing of cord blood

Cord blood can be collected in 5 minutes, irrespective of the type of delivery (vaginal or caesarean). This is done using either a syringe or a bag pre-labelled with a number unique to your baby. Blood is drawn from the umbilical cord with the syringe or it may be elevated to drain the blood into the bag. It is important that cord blood is collected during the first 15 minutes following delivery. The blood is then processed and stored in a laboratory (blood bank) within 48 hours.

Benefits

Cord blood collection is safe and does not pose any risk to either mother or baby. The procedure is simple and painless. Your baby's cord blood has wonderful healing capabilities and can be used to treat over 80 different diseases currently. Cord blood banking ensures you have options should the need arise to help other family members who may be diagnosed with various cancers and blood diseases. Also, it could help another family as blood transplants from unrelated donors can be used to treat disease conditions.

A normal pregnancy is of about 40 weeks' duration. A baby born between weeks 32 and 37 of pregnancy is a preterm baby. An early preterm birth occurs when a baby is born before 32 weeks. Early preterm babies often have serious, long-term health problems. They may suffer from physical or mental disabilities that require special medical care.

What are the effects of early preterm birth?

Health problems

The longer the baby is in the mother's womb, the more likely he or she will be healthy. Early preterm babies may have respiratory and digestive problems. They are also at a higher risk of brain and related neurological complications.

Treatment

Treatment is provided in the form of medications. Corticosteroid injections are given to speed the development of your baby's lungs and other organs. A delivery date can be extended by 2 to 7 days with drugs called tocolytics that work to slow or stop contractions of the uterus. The extra time gained can be used to take corticosteroids or to get to a hospital specialising in preterm care for babies.

Women at risk

Some woman deliver an early premature baby for no apparent reason. However, certain factors may increase a woman's risk of early preterm birth. Some of them include lifestyle risks (for example: smoking, drinking), woman

pregnant with multiples, chronic illnesses and short time between pregnancies.

What is group B Streptococcus?

Group B Streptococcus (GBS) is a type of bacteria that may be present in a woman's vagina or rectum, although it is not a sexually transmitted disease. It is usually harmless; however, if present in pregnant women, it can cause serious health problems if passed to a newborn during delivery.

What are its symptoms?

Most pregnant women with GBS show no symptoms. Some may develop a urinary tract infection or infection of the uterus. However, a woman infected with GBS in the later stages of pregnancy can pass the bacteria to her baby during the delivery process causing complications for the baby. GBS symptoms in a new born baby may occur in the first 24 -48 hours following birth (early onset infections) or after 1 week to several months (late onset infections) and can lead to a blood infection, lung infection or meningitis in the newborn. Early onset infections are characterised by shortness of breath and lethargy whereas high fever, vomiting, poor feeding and irritability are characteristic of late onset infections in newborns.

How to detect GBS in pregnancy?

GBS can be detected during weeks 35 and 37 of pregnancy with a culture test. Using a swab, a sample is taken from the women's vagina and rectum and sent for laboratory testing.

What are the treatment options?

If the test result is positive for GBS, IV antibiotics are given during labour to protect the newborn from contracting it from the mother. Penicillin is the commonly prescribed antibiotic but alternative antibiotics can be provided if you are allergic to penicillin.

What is a breech baby?

Usually in the last month before birth, most babies position themselves head down in the mother's womb so they come out of the vagina (birth canal) head first. Sometimes, however, the buttocks or feet emerge first during childbirth. This is called a breech presentation. Most breech babies are born by a planned caesarean delivery (though an incision made in the mother's abdomen) which is associated with certain complications such as infection and bleeding.

If your baby is breech, it might be positioned in any one of the following ways:

• Frank breech: Upwardly positioned feet and legs near the baby's head
• Complete breech: Folded legs with feet at the level of buttocks
• Footling breech: Either one or both feet point down so that legs emerge first during delivery

How is it diagnosed?

Diagnosis of a breech presentation involves a physical examination of your abdomen to feel the baby's shape and location. Ultra sound may be needed to confirm the placement of the baby.

What are the treatment options?

External cephalic version (ECV)

If a breech presentation is determined, your doctor may advise a procedure called External cephalic version or ECV, ideally performed when you are at least 36 weeks pregnant. In this procedure, the doctor places his or her hands at certain positions of the abdomen, then lifts and turns the baby from the outside to enhance the chances of a normal delivery.

If ECV is done before 36 weeks, there is a possibility that the baby may revert to breech position and will need to be repeated. Also, ECV becomes more difficult near the due date, as the baby would be growing bigger each day, leaving less room for movement.

Your due date is an estimate of the date of delivery and determined based on the date of your last period. Your physician uses this date to assess the progress of your pregnancy and baby's growth in the womb. The due date may be confirmed or updated after ultrasound is performed between 18 and 20 weeks of pregnancy. Usually the due date is 40 weeks after the first day of your last period with most babies arriving between 37 and 41 weeks. A post term pregnancy is described as lasting 42 weeks or more.

What are the risks related to Post Term Pregnancy?

When a pregnancy exceeds 42 weeks, there is a small risk of the baby being stillborn. The causes for such deaths have not been established with certainty but probable reasons include reduced efficiency of placenta (tissue that provides nourishment to the foetus) and a decrease in amniotic fluid levels. Other risks to the baby include meconium aspiration, neonatal acidemia, low Apgar scores, macrosomia (excess birth weight) which can lead to birth injury.

What are the tests used to determine the health of the baby in post-term pregnancies?

The health of a baby not born by the due date is determined with the help of a few tests. Certain tests, such as a "kick count" can be done by the expecting mother herself. This test is a record of how often the mother feels the baby moving. Other tests such as electronic foetal monitoring involve measuring foetal heart rate and strength of uterine contractions by placing instruments under belts wrapped around the mother's abdomen.

Inducing labour

Most hospitals suggest inducing labour (causing a pregnant woman's cervix to open and to prepare for vaginal birth) at 42 weeks. IV medications are used to bring on labour but if these fail, other methods are used, which include using prostaglandins (naturally occurring fatty acids) and special devices to soften and dilate the cervix, rupturing the amniotic sac to release the fluid, stripping or sweeping the amniotic membranes (thin membranes that connect the amniotic sac to the uterus wall) and using hormones for contracting the uterus.

Antenatal care includes regular medical visits, screening tests, and diagnostic tests to help assess your health status to keep you and your baby in a healthy condition during your pregnancy. The routine visits to the doctor are scheduled so that any problems present may be recognised and treated well in advance. These visits also educate you on handling various aspects of your pregnancy. Read more

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Pregnancy is an exciting time for any women, but complications may develop sometimes even in healthy women. Most pregnancy complications can easily be detected and prevented during regular prenatal visits. The two most common complications that arise during pregnancy are high blood pressure and gestational diabetes. Read more

What is birthing/Labour?

Birthing is the act or process of giving birth to offspring. Labour or childbirth experience may differ in every woman. Common initial signs of labour include strong regular contractions, backache, draining of water (amniotic fluid) or sticky and mucous-like substance through the vagina. The average time for which you will be in labour may be approximately 12-18 hours.

What are the risks associated with labour?

The most common risks and complications that may occur during labour are discussed below:

Preterm Labour

Preterm labour is said to have occurred when you have strong contractions before 37 weeks of your pregnancy whereas the gestation period normally is 38 to 40 weeks. A baby if born prematurely will be at risk of complications such as immature lungs, respiratory distress, and problems in digestion as the organ systems would not have developed completely to support survival.

Your doctor will manage this situation with medications that stop labour or prevent infection. Also, medications that accelerate the baby’s lung development may be given. You will be advised to take bed rest usually lying on the left side.

Prolonged labour

Some women, most often during their first pregnancy, may go through a labour that lasts for too long. Prolonged labour may lead to infection in case the amniotic sac has ruptured. Anti-infective medications may be administered to prevent infection.

Abnormal Presentation

During labour, the baby normally moves to a head-down position with the back of the head ready to enter the pelvis. Sometimes, the baby may present with buttocks or feet first towards the birth canal. This is called breech presentation. In some conditions, the placenta may block the cervix (placenta previa) and cause abnormal presentation.

Abnormal presentation increases the risk of injuries to the uterus or birth canal as well as the foetus. Breech presentation may lead to a prolapsed umbilical cord which can cut off the blood supply to the foetus. Your doctor will check the presentation and position of the baby with physical examination and ultrasound scan. Assisted delivery methods may be adopted in such cases.

Premature Rupture of Membranes

Rupture of the membranes that surround the foetus in the uterus may occur prematurely leading to high risk of infection. In these cases, immediate delivery of the foetus will be done.

Umbilical Cord Prolapse

The umbilical cord which transports oxygen and nutrition to the baby may slip into the cervix before the baby during labour. The cord may be felt if it protrudes from the vagina. This is an emergency as the blood flow to the baby through the umbilical cord may get obstructed.

Umbilical Cord Compression

During labour, the umbilical cord may get compressed leading to decreased blood flow to the foetus. This causes abrupt drop in the foetal heart rate. In cases where the foetal heart rate has worsened or there are signs of distress, your doctor may consider a Caesarean section.

Amniotic Fluid Embolism

Amniotic fluid embolism occurs when a small amount of amniotic fluid from the amniotic sac enters your bloodstream during a difficult labour. This fluid may travel up to the lungs and cause constriction of the lung arteries leading to a rapid heart rate, irregular heart rhythm, cardiac arrest and death.

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Caesarean section also called C-section is a non-vaginal delivery of a baby. It is a surgical procedure of delivering a baby through incisions made in the abdomen and uterus of a pregnant woman. Your doctor may decide to perform a C-section if your condition is unsafe to go for a vaginal birth. Most of the times, it may be done when unexpected complications arise during labour however at times pregnant women may prefer C-section rather than normal vaginal delivery. Some of the conditions in which a C-section your obstetrician may recommend caesarean delivery include:

• Twin or multiple pregnancy
• Labour does not progress - The uterine contractions may not be enough to cause dilation of the cervix and allow baby to move into the birth canal
• Foetal complications - Umbilical cord compression or abnormal heart rate
• Placental problems - The placenta may detach from the uterus before delivery, the condition called placenta abruptio
• Large-sized baby - The head of the baby may be large enough and the birth canal may be small comparatively to allow safe normal delivery
• Abnormal presentation - Breech baby or baby is in an abnormal position
• Maternal conditions and infections - Conditions such as maternal diabetes or maternal high blood pressure and maternal infections such as human immunodeficiency virus or herpes

Your doctor may recommend a C-section also if you have had C-section during your previous pregnancy. In conditions such as placenta previa, where your placenta lies too low in the uterus and blocks the birth canal, your doctor may suggest a C-section when it is diagnosed by ultrasound several weeks before delivery.

In the current scenario, C-section delivery is done not only because of medical complications but also some women choose C-section though the medical necessity doesn't exist. This is elective C-section or parent-choice C-section. Some of the reasons why some women choose C-section include:

• Fear of the delivery pain
• Fear of unpredictable outcomes
• Concern about sexual life in future
• Avoid the uncomfortable experiences of previous vaginal birth
• To avoid the possible medical conditions such as incontinence and perineal damage
• Personal issues such as their family and work place issues

Obstetricians may do counselling and convince the patients for normal vaginal delivery for safe and successful vaginal deliveries, unless if they anticipate some medical complications.

Preparation for Caesarean Delivery

Once you are moved into surgery room, an intravenous line through which fluids and medications are given during the surgery is placed in a vein of your arm. Anti-infective medicines may be administered to prevent infection. A thin tube or catheter will be placed in the urethra so as to drain the bladder and keep it empty during the procedure. A general anaesthesia, an epidural block or a spinal block will be administered. Then your doctor will make two incisions, one through the skin and the abdominal wall and the second one through the uterus. The abdominal wall incision is made 6 inches in length and the incision passes into the skin, fat and muscles. It can be either a vertical or a horizontal incision. The abdominal muscles are moved apart. After this incision, uterus is opened to remove the baby through another cut made depending on the position of the baby. Once the baby is out, your doctor will clamp and cut the umbilical cord and remove the placenta. Then the uterine incision is closed using absorbable stitches and abdominal incision may be closed with stitches or staples.

If you are awake during delivery you can see your baby soon after the birth. Following C-section, you will be shifted to recovery room. The catheter and IV line will be removed and a nurse or your care takers will help you to get out of bed for some time. You may be prescribed medications to get rid of pain or heating pads may be recommended. You will be asked to stay in the hospital for next 2-4 days after the C-section. You can start breast-feeding and you will be guided by nurse or your obstetrician for the same. After you move home you may experience mild cramps, bleeding and pain at the incision site. Avoid sex or strenuous activities that may impart stress on abdomen for few weeks after delivery to avoid infections and other complications.

What is pre-pregnancy assessment and counselling?

Reviewing the overall health of you and your partner before conception helps you make healthy choices for both you and your baby. All women are recommended to visit their doctor for a pre-pregnancy counselling appointment to check for possible risk factors that could affect your chances of conceiving or having a normal pregnancy. Following the counselling, you can address and resolve any medical issues that you may have before you conceive.

What are the issues addressed during pre-pregnancy counselling?

At your pre-pregnancy counselling, your health care provider may discuss the following with you:

• Medical history: your past or existing medical conditions and allergies, over-the-counter and prescribed medications you are currently taking, previous surgeries and reasons for hospitalisation
• Family history: medical, congenital, genetic and ethnic-related conditions that run in your family such as diabetes, hypertension, deafness, blindness and mental retardation
• Lifestyle habits: lifestyle habits such as drinking, smoking or use of recreational drugs, stress, diet and exercise, which can influence your pregnancy
• OB/GYN history: menstrual history, sexually transmitted diseases, vaginal infections, previous pregnancies and contraceptive use
• Menstrual cycles: help determine the period during which you are most likely to get pregnant
• Home and workplace safety: exposure to X-rays, cat faeces, solvents or leads

Your doctor may also perform a physical examination, which includes assessment of your breasts, heart, abdomen, lungs, thyroid and pelvic examination. Your blood pressure will be checked and weight measured. Lab tests such as complete blood count (CBC), rubella, Pap smear, HIV and hepatitis may also be ordered.

You will be prescribed prenatal vitamins with folic acid. Your health care provider may suggest lifestyle changes based on the examination to help ensure a healthy pregnancy.

What is repeated miscarriage?

Repeated miscarriage is the occurrence of two or more consecutive miscarriages. About one woman in 100 experiences this condition; however, many of these women go on to have a successful pregnancy later. All the causes leading to this condition are not known. There are, however, a few known causes that include abnormal genetic makeup of the embryo Read more

What is early pregnancy genetic counselling?

Early pregnancy genetic counselling involves counselling a pregnant woman about her chances of having a child with a genetic disorder or birth defect as well as the different testing and treatment options available. Specially trained genetic counsellors provide information which helps to identify families at risk of genetic diseases and risks associated with specific chromosomal and foetal abnormalities.

Relevant genetic tests are ordered after reviewing the family history and medical records. The counsellor interprets the technical and scientific information of the genetic test results to the parents. The parents can then make informed decisions in consultation with their counsellor.

Who is a candidate for genetic counselling?

Candidates for prenatal genetic counselling:

It is always advisable to seek genetic counselling when planning for pregnancy. However, a meeting with the genetic counsellor after becoming pregnant is also helpful to minimise potential risks. Prenatal genetic counselling becomes more important for candidates:

• 33 years and older
• With a family history of any genetic disorder
• With abnormal ultrasound or blood test results
• Exposed to certain medications during pregnancy
• Affected with any infections during pregnancy
• Whose previous pregnancies were translated into miscarriages
• Who are infertile

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