Common risks in Third Trimester include:
Preterm labour
This is the onset of regular painful contractions after 24 weeks and before 37 weeks gestation. The earlier the onset of labour, the worse the outcome. If you do experience regular painful contractions during this time, come in early to the hospital. Regular painful contractions could occur once every 5-10 minutes interval, and may last about 20-40 seconds in duration. Medications could be given to inhibit the labour (i.e. tocolytics), corticosteroids could be given to help reduce the possibility of breathing difficulties to the baby should the delivery occur despite the inhibition of labour, and magnesium sulphate could be given to reduce the possibility of cerebral palsy if the delivery happens before 32 weeks.
Preterm leaking liquor
This is the leakage of colourless fluid from the vagina after 24 weeks and before 37 weeks gestation. The earlier the onset, the worse the outcome. If you do experience leaking liquor, come in quickly to the hospital. Complications include preterm labour and chorioamnionitis (i.e. infection of the placenta and membranes). Corticosteroids to reduce the possibility of breathing difficulties to the baby may be given, and medications to inhibit the labour may be given if there is no chorioamnionitis.
Pre-eclampsia (PE)
This is a pregnancy-induced condition that is characterised by high blood pressure (i.e. blood pressure persistently at or above 140/90 mmHg) and proteinuria (i.e. proteins in the urine) usually in the third trimester. Proteinuria usually implies involvement of the kidneys. If this occurs, further blood tests and ultrasound examination of the fetus may be required to assess the extent of this condition, and close surveillance required. Some cases of pre-eclampsia progress quickly while others progress slowly. It could progress to involve other systems including fits, bleeding in the liver, bleeding disorders, and other serious complications. Delivery is necessary when the PE progresses significantly. The risk of PE can be assessed now at the 11-13 weeks scan.
Gestational diabetes mellitus (GDM)
This is a pregnancy-induced condition that is characterised by high blood sugar level. This is usually diagnosed from an oral glucose tolerance test at 28 weeks gestation. For this test, you need to fast overnight from 10 pm. There is a 75 g of sugar drink to be taken orally in the morning, with blood taken before taking this drink and 1 and 2 hours after the drink. If the fasting blood glucose is 5.1 or more, 1st hour post-drink is 10.0 mmol/l or more, and 2nd hour post-drink is 8.5 mmol/l or more, you have gestational diabetes mellitus.
Gestational diabetes mellitus, especially if not well controlled, increases the risk of macrosomia, shoulder dystocia, Caesaraean section and stillbirth.
Treatment includes:
1. Dietary modification with restriction of calories and carbohydrates.
2. Regular physical exercise
3. Need for home blood sugar profile (BSP) of at least 7 readings in 1 week.
4. If BSP pre-meals persistently >= 5.3 mmol/l (95 mg/dl), 1st hour post-meals persistently >=7.8 mmol/l (140 mg/dl) and 2nd hour post-meals persistently >= 6.7 mmol/l (best 5.9-6.4 mmol/l or <120 mg/dl), or HbA1c >6.0 - 6.5%, may require oral medications like metformin.
5. If BSP still poor despite metformin, may require insulin injections. This occurs in about 20-30% of patients who were initially started with metformin.
6. Timing of delivery - usually between 38-40 weeks.
Intrauterine growth restriction (IUGR)
This is diagnosed when the estimated fetal weight is smaller than usual, or if there is a reduction in the growth velocity of the estimated fetal weight. If this is due to poor placental function, it is often accompanied by adverse blood flow changes in the fetus and reduced amniotic fluid. Premature delivery may be indicated if it is judged that early delivery is safer than keeping the fetus within the uterus.
Macrosomia
This is diagnosed when the estimated fetal weight is larger than usual. A potentially more difficult vaginal delivery is anticipated when the fetus is too large. This could result in Caesarean section, forceps / vacuum delivery, difficult vaginal delivery sometimes with obstruction of the shoulder after the head is delivered. Inherently the estimated fetal weight is accurate within a 15% margin of error. For a large fetus measuring 4 kg, this could mean that the actual fetal weight ranges from 3400 g to 4600 g. If the measurements are done serially, the margin of error may be reduced.
Advice:
If the fetal movements is more than 10 times during that 2 hours, it is reassuring.
Report to the hospital if the fetal movements is less than 10 times during the 2 hours. Often it is a false alarm, but it does make sense to have a check of the baby to ensure that the baby is healthy when the fetal movement is markedly reduced.
When to come to labour ward / delivery suite ?
The Raffles Hospital labour ward's number is 63111500 / 1501.
Preterm labour
This is the onset of regular painful contractions after 24 weeks and before 37 weeks gestation. The earlier the onset of labour, the worse the outcome. If you do experience regular painful contractions during this time, come in early to the hospital. Regular painful contractions could occur once every 5-10 minutes interval, and may last about 20-40 seconds in duration. Medications could be given to inhibit the labour (i.e. tocolytics), corticosteroids could be given to help reduce the possibility of breathing difficulties to the baby should the delivery occur despite the inhibition of labour, and magnesium sulphate could be given to reduce the possibility of cerebral palsy if the delivery happens before 32 weeks.
Preterm leaking liquor
This is the leakage of colourless fluid from the vagina after 24 weeks and before 37 weeks gestation. The earlier the onset, the worse the outcome. If you do experience leaking liquor, come in quickly to the hospital. Complications include preterm labour and chorioamnionitis (i.e. infection of the placenta and membranes). Corticosteroids to reduce the possibility of breathing difficulties to the baby may be given, and medications to inhibit the labour may be given if there is no chorioamnionitis.
Pre-eclampsia (PE)
This is a pregnancy-induced condition that is characterised by high blood pressure (i.e. blood pressure persistently at or above 140/90 mmHg) and proteinuria (i.e. proteins in the urine) usually in the third trimester. Proteinuria usually implies involvement of the kidneys. If this occurs, further blood tests and ultrasound examination of the fetus may be required to assess the extent of this condition, and close surveillance required. Some cases of pre-eclampsia progress quickly while others progress slowly. It could progress to involve other systems including fits, bleeding in the liver, bleeding disorders, and other serious complications. Delivery is necessary when the PE progresses significantly. The risk of PE can be assessed now at the 11-13 weeks scan.
Gestational diabetes mellitus (GDM)
This is a pregnancy-induced condition that is characterised by high blood sugar level. This is usually diagnosed from an oral glucose tolerance test at 28 weeks gestation. For this test, you need to fast overnight from 10 pm. There is a 75 g of sugar drink to be taken orally in the morning, with blood taken before taking this drink and 1 and 2 hours after the drink. If the fasting blood glucose is 5.1 or more, 1st hour post-drink is 10.0 mmol/l or more, and 2nd hour post-drink is 8.5 mmol/l or more, you have gestational diabetes mellitus.
Gestational diabetes mellitus, especially if not well controlled, increases the risk of macrosomia, shoulder dystocia, Caesaraean section and stillbirth.
Treatment includes:
1. Dietary modification with restriction of calories and carbohydrates.
2. Regular physical exercise
3. Need for home blood sugar profile (BSP) of at least 7 readings in 1 week.
4. If BSP pre-meals persistently >= 5.3 mmol/l (95 mg/dl), 1st hour post-meals persistently >=7.8 mmol/l (140 mg/dl) and 2nd hour post-meals persistently >= 6.7 mmol/l (best 5.9-6.4 mmol/l or <120 mg/dl), or HbA1c >6.0 - 6.5%, may require oral medications like metformin.
5. If BSP still poor despite metformin, may require insulin injections. This occurs in about 20-30% of patients who were initially started with metformin.
6. Timing of delivery - usually between 38-40 weeks.
Intrauterine growth restriction (IUGR)
This is diagnosed when the estimated fetal weight is smaller than usual, or if there is a reduction in the growth velocity of the estimated fetal weight. If this is due to poor placental function, it is often accompanied by adverse blood flow changes in the fetus and reduced amniotic fluid. Premature delivery may be indicated if it is judged that early delivery is safer than keeping the fetus within the uterus.
Macrosomia
This is diagnosed when the estimated fetal weight is larger than usual. A potentially more difficult vaginal delivery is anticipated when the fetus is too large. This could result in Caesarean section, forceps / vacuum delivery, difficult vaginal delivery sometimes with obstruction of the shoulder after the head is delivered. Inherently the estimated fetal weight is accurate within a 15% margin of error. For a large fetus measuring 4 kg, this could mean that the actual fetal weight ranges from 3400 g to 4600 g. If the measurements are done serially, the margin of error may be reduced.
Advice:
- Organise your logistics
- Arrange work schedule; start handing over work to colleagues
- Organise help at home
- Get ready baby’s necessities
- Frequent fetal movement is reassuring.
If the fetal movements is more than 10 times during that 2 hours, it is reassuring.
Report to the hospital if the fetal movements is less than 10 times during the 2 hours. Often it is a false alarm, but it does make sense to have a check of the baby to ensure that the baby is healthy when the fetal movement is markedly reduced.
You could download and read any of these brochures in the different languages:
Baby's movement in pregnancy (UK)
http://www.stillbirthalliance.org.au/doc/ANZSA_DFM_brochure_English.pdf
http://www.stillbirthalliance.org.au/doc/ANZSA_DFM_brochure_Chinese_Simplified.pdf
http://www.stillbirthalliance.org.au/doc/ANZSA_DFM_brochure_Korean.pdf
Baby's movement in pregnancy (UK)
http://www.stillbirthalliance.org.au/doc/ANZSA_DFM_brochure_English.pdf
http://www.stillbirthalliance.org.au/doc/ANZSA_DFM_brochure_Chinese_Simplified.pdf
http://www.stillbirthalliance.org.au/doc/ANZSA_DFM_brochure_Korean.pdf
When to come to labour ward / delivery suite ?
The Raffles Hospital labour ward's number is 63111500 / 1501.
You are not expected to deliver before 37 weeks. Hence if you think that you have symptoms of labour before 37 weeks such as regular painful contractions, vaginal bleeding or leaking of liquor, come straight to the hospital.
Once you have reached 37 weeks, come to the labour ward / delivery suite if you have any of the following symptoms or signs:
Tests:
- Regular painful contractions of about 1 every 5 minutes, or earlier if the pain is significant and you would require pain relief.
- Leaking liquor - this manifests as leakage of usually colourless fluid from the vagina and is usually in moderate to large amounts and may occur in gushes.
- Decreased fetal movement
- Show - this is blood mixed with mucus from the vagina, and usually in small amounts. Though this may precede labour, it is an unreliable predictor as to when regular painful contractions would start. Report to the hospital only if the vaginal bleeding is heavy or if you are still less than 37 weeks.
Tests:
- Blood pressure and urine for protein at every visit - Screens for pre-eclampsia
- Full blood count, serum ferritin, and 3-point oral glucose tolerance test (OGTT) at 28 weeks - Routine screening for anaemia, iron deficiency and gestational diabetes mellitus (GDM) using the latest FIGO guidelines.
- Growth scan (including 3D / 4D) - Measurements of head circumference, abdominal circumference and femur length to demonstrate the growth of the fetus. 3D and 4D scans promote fetal bonding.
- Low vaginal and rectal swab for Group B streptococcus (GBS) at 35-37 weeks - There is a choice between the US approach vs the UK approach in this screening test. There has not been a direct comparison between both approaches and hence it is not clear which strategy is superior. Let me know which strategy you prefer. By default, if you have not opted out of the screening, I assume that you prefer to be screened and hence agree to adopt the US approach.
The UK approach is different in that there is no need for GBS screening. Instead risk factors for early GBS infection in the baby are identified. These include: previous GBS-infected infant, GBS infection in the urine or vaginal / rectum taken for another reason in the current pregnancy, premature labour before 37 weeks, rupture of membranes more than 18 hours, and fever during labour. If any of these risk factors are present, antibiotic treatment is given during labour without a need for the swab test. See More patient information on UK's approach to GBS prophylaxis.
Graph from US CDC report in 2010 showing efficacy of the US approach
Graph from US CDC report in 2010 showing efficacy of the US approach
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