2nd Trimester Overview
The issue of fetal viability dominates triage concerns during the 2nd trimester of pregnancy. Depending on the practice setting and the proximity to neonatal intensive care facilities, the ability of a baby to survive outside of the uterus may vary considerably. Issues of recognizing and stopping preterm labor (if possible) are paramount. Understanding the importance of intervention at different points throughout the 2nd trimester is key to successful triage of patient concerns.
The physical complaints of pregnancy increase as the pregnancy progresses, but many women feel quite well during the 2nd trimester. Early pregnancy symptoms are typically resolving, concerns about early miscarriage have waned, and ambivalence has lifted for most women. This is a time when many women are working, assuming full child care responsibilities, and planning for a future addition to the family. There may be little time to be “slowed down” by pregnancy complaints.
Because of concerns of the consequences of preterm labor, all practices should establish a standard as to what is acceptable and what is not with respect to patient contractions during this point in pregnancy. Many providers educate patients to call if they have four or more contractions per hour, each lasting 45 to 60 seconds, with or without accompanying pain. Furthermore, many practices provide patients with instructions for “first-line evaluation” of such symptoms. Common instructions include lying on the left side, consuming a quart of water, and observing for regular uterine tightening over the course of an hour.
The standard for monitoring of preterm labor in our practice is: _______________________ ___________________________________________________________________________________________.
Our recommendations for evaluating symptoms at home are: _______________________________ ___________________________________________________________________________________________.
2nd Trimester Abdominal Pain
» Key Questions
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STEP A: Vaginal Bleeding Associated With Abdominal Pain
A patient who is bleeding “like a period” (or heavier than a period) needs to be seen as soon as possible (ASAP) in an appropriate facility. The patient should not drive herself. Transportation to the appropriate facility will depend on your location, the patient’s location, and the availability of necessary services.
If the bleeding is “less than a period,” the patient still needs to be seen ASAP to ensure that she is not experiencing preterm labor or placental problems.
Risk factors for preterm labor include:
history of a preterm birth (prior preterm labor/birth increases the risk by 17% to 37%);
multiple gestation (10% of such pregnancies result in premature delivery);
maternal smoking or cocaine use;
no prior prenatal care;
long working hours with reported fatigue;
maternal medical or obstetric complications;
uterine abnormalities, such as fibroids or a bicornuate uterus;
cervical incompetence; and
Diethylstilbestrol (DES) exposure (may affect women born before 1972 and is highly unlikely in current practice; however, this is still listed as a risk in some material).
STEP B: Symptoms Consistent With Contractions
The patient may be experiencing an onset of preterm labor or an acute abdominal problem.
Symptoms of preterm labor include:
abdominal cramps;
abdominal pressure;
low backache;
increased vaginal discharge;
pain radiating down thighs;
bowel changes, especially diarrhea;
vaginal spotting or bleeding; and
leaking fluid.
Have patient time contractions. (See Patient Education for description of timing contractions.)
If the patient reports four or more contractions in an hour, each lasting 45 to 60 seconds, have patient get in a comfortable position and do the following:
Lie on left side.
Drink 1 quart of water.
Monitor contractions for 1 hour.
Call back immediately if symptoms worsen; otherwise, report in 1 hour.
If symptoms continue but do not worsen, patient should be seen within 1 to 3 hours for evaluation.
If symptoms subside, advise the patient to rest for the remainder of the day and call in the morning to report how she is feeling.
If there is any suspicion of preterm labor or an acute abdominal complaint, the patient should go to the emergency room (ER), the labor, and delivery unit or the clinic/office. The decision of which facility to send the patient is usually based on potential for fetal viability.
STEP C: Pain Confined to One Part of Abdomen, Relieved by Position Change
The patient may be experiencing round ligament pain.
Have the patient describe the location of pain. If the pain is in the right or left lower quadrant, this may be round ligament pain.
Advise the patient to avoid sudden position change and to support her abdomen when she coughs.
Have her call back if the symptoms increase, particularly if there is right lower quadrant pain.
If the pain is in another region of the abdomen but still is relieved with position change, have the patient monitor her symptoms and call back if the symptoms increase or are accompanied by other symptoms. If symptoms persist beyond 24 hours, the patient should be seen for evaluation.
STEP D: Pain Confined to One Part of Abdomen, Not Relieved by Position Change
Question the patient as to area of pain.
Record the frequency, duration, and severity of the pain.
Forward a message to the patient’s provider so follow-up can be made within the hour.
STEP E: Pain Associated With Other Symptoms
Remember that diarrhea may be associated with preterm labor.
Appendicitis: If the patient still has her appendix and the pain is in the right lower quadrant or the patient is experiencing bowel changes, she should be seen ASAP or sent to an emergency room (ER) or urgent care center for an acute abdomen evaluation.
Gallbladder Attack: If the pain is in the right upper quadrant or to the right of the sternum, particularly if the patient has a history of gallstones, or the pain is associated with eating, the patient should be seen by her primary care provider within 24 hours, or sooner if symptoms increase.
Gastrointestinal Complaints: Bowel changes, nausea, or vomiting associated with malaise or other flu-like symptoms may indicate gastritis, particularly if other family members are experiencing similar symptoms. If there are no other complications, the condition may be managed at home. (See Patient Education.)
Refer the patient to her physician or the ER if she has:
increasing fever;
pain localized on right side (either lower or upper right quadrant) to exclude appendicitis or portal hypertension;
symptoms not resolving within 12 to 24 hours; or
signs of significant dehydration, including the inability to keep down any fluids (even sips of water), no urine output in the past 8 hours, or dizziness.
Urinary Tract Infection: If the patient experiences pain on urination or has unusually frequent urination, arrange for the patient to provide a urine sample for culture that day. If the patient is experiencing low backache or flu-like symptoms, such as nausea, vomiting, or fever, she should be seen ASAP to evaluate for a kidney infection.
» Patient Education
Monitoring for Contractions
Patients should be taught to monitor for contractions by doing the following:
Place your hands lightly on each side of your abdomen.
If the uterus tightens beneath your hands, you are contracting, whether or not you are experiencing pain.
Time from the beginning of one contraction to the beginning of the next.
Time the length of the contraction as the amount of time your uterus tightens.
Call back if you are contracting four times or more in an hour, with contractions lasting 45 to 60 seconds; if symptoms rapidly escalate; if you are bleeding; if you are leaking fluid from the vagina; or if contractions are accompanied by bowel changes.
Some women experience more abdominal discomfort than do others, more contractions than do others, and more pain in general. These women will need help in establishing what is normal for them and need to feel confident they can call with symptoms any time.
Gastritis
Modify the diet for the next 24 hours.
Avoid milk/milk products
Slowly rehydrate with sips of water (two sips of water every 5 to 10 minutes)
Progress to clear liquids
Slowly begin BRAT (bananas, rice, applesauce, and toast) diet after tolerating clear liquids.
Call primary care provider to schedule a same-day appointment if:
symptoms do not begin to resolve in 12 to 24 hours,
symptoms increase in intensity (more vomiting, diarrhea),
fever begins, or
the patient has any concerns whatsoever.
2nd Trimester Anxiety/Depression
There are several contributing factors to anxiety and depression in the 2nd trimester. Even though ambivalence that can occur in early pregnancy has usually subsided by this point, options for a woman still experiencing significant ambivalence have diminished. As choices involving pregnancy termination are reduced, women considering adoption may experience considerable anxiety and/or depression. As well, women who have suffered previous pregnancy loss or poor pregnancy outcomes may become exceedingly anxious approaching the gestational age when previous problems arose. Aside from offering further assessment and possible counseling and/or other treatment, fetal surveillance testing as described in Chapter 7 may provide reassurance for women in this situation, depending on gestational age.
» Key Questions
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STEP A: Anxiety in Pregnancy/Assessment and Treatment of Panic Attacks
Panic disorders are twice as common in women as in men. People with panic disorder have sudden attacks of terror when there is no actual danger. Panic attacks may cause a sense of unreality, a fear of impending doom, or a fear of losing control. A fear of one’s own unexplained physical symptoms is also a sign of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or dying. They are particularly unsettling in pregnancy as the patient may also be worried about the impact of the panic attack on the developing fetus.
If the patient is experiencing uncontrolled fear and anxiety, coupled with physical symptoms, do the following:
Determine if there is anyone else present with the patient with whom she feels comfortable. It is particularly important to know if there is anyone nearby who is making the patient uncomfortable. Women with a history of abuse, sexual victimization, posttraumatic stress disorder (PTSD), or other trauma may experience symptoms related to panic when confronted by what they perceive as a threatening situation. It is not uncommon for others around the woman not to perceive the same level of threat or any threat at all. Have her remove herself from the situation if possible and align herself with someone with whom she feels safe.
Have her do the following for self-help:
First, ask her to become aware of any tension that she may be feeling. Ask her to take a deep sigh and relax her shoulders.
Provide reassurance (the triage personnel will be able to hear if she has taken a deep sigh; if not, repeat that command). Instruct her to gently progressively tense and relax all the large muscle groups. For example, instruct her to tighten her right leg while taking a deep breath in. Then, have her hold the breath for a few seconds, release the tense leg, and let the breath out. Repeat this with muscle groups working back up to her shoulders.
Ask her to continue to slow down her breathing. Having her place a hand on her stomach may allow her to further control her symptoms by feeling her breathing slowing down.
If a patient has been diagnosed with any serious medical illness which may also present with similar physical symptoms, particularly cardiovascular disease, advise this patient to seek same-day treatment in an urgent care center, an emergency department, or with her regular health care provider. Home treatment may not be appropriate, even if this patient has experienced previous panic attacks. Certain medical conditions (notably heart disease and asthma) may be mimicked or worsened by panic. Depression, irritable bowel syndrome, and chronic pain may also be worse with severe anxiety.
Talking with a partner, significant other, close friend, or family member may be beneficial for some patients.
In cases of an unplanned pregnancy, it may be helpful to talk to a counselor throughout the pregnancy to keep track of emotions.
In our practice, we recommend the following counselors who may be of value in helping to sort out feelings of ambivalence and pregnancy continuation: __________________________ __________________________________________________________________________________________.
STEP B: Possible Underlying Depression or Anxiety
Major life events may unmask or precipitate depression or anxiety. If there is any question that the patient is experiencing uncontrolled mood swings, thoughts about harming herself or others, feeling out of control, or becoming withdrawn, do the following:
Make a same-day appointment for the patient with a mental health provider and ensure that a friend, family member, or social services worker accompanies the patient to the appointment.
Ensure that a high-risk patient is not left alone.
If necessary, have another person in your office call emergency services and remain on the line with the patient until help arrives.
Notify a provider in your practice of the problem and your actions.
If patient is of no danger to herself or others, do the following:
Refer the patient to a mental health counselor within the next 3 to 5 days.
Reassure the patient that she may call back at any time if symptoms worsen.
Your practice should have a system for identifying patients possibly at risk for depression early in pregnancy.
In our practice, we do the following to identify patients at risk for depression during pregnancy (and thus, possibly postpartum depression): _____________________________________________________ ___________________________________________________________________________________________________.
STEP C: History of Depression or Previous Mental Health Issues
Patients with a history may be at greater risk with a new pregnancy.
Repeat actions in Step B.
STEP D: Desire to Harm Oneself or Others
If the patient is experiencing uncontrolled mood swings, thoughts about harming herself or others, feeling out of control, or becoming seriously withdrawn, do the following:
Make a same-day appointment for the patient with a mental health counselor and ensure that a friend, family member, or social services worker accompanies the patient to the appointment.
Ensure that a high-risk patient is not left alone.
If necessary, have another person in your office call emergency services and remain on the line with the patient until help arrives.
Notify a provider in your practice of the problem and your actions.
» Patient Education
Reassuring a patient that ambivalence is common in early pregnancy may be reassurance enough that her thoughts are not abnormal. However, expressions of increasing ambivalence as the 3rd trimester approaches may signal other problems.
Patients with a history of depression during pregnancy or the postpartum period need education regarding the possible recurrence and to know that help is available. Avoid being judgmental. Many patients have the misconception that all feelings can be controlled by will.
2nd Trimester Backache
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STEP A: Preexisting Back Condition
It is common for preexisting back conditions to become aggravated during the 2nd trimester.
Determine the nature of the preexisting problem.
Question the patient as to whether she has seen a health care provider regarding her condition before pregnancy.
Continue with questions to eliminate any acute problem before encouraging the patient to call her regular health care provider if she has not done so during this pregnancy.
Refer to Patient Education.
STEP B: Backache Accompanied by Possible Contractions
This patient may be experiencing onset of preterm labor.
Have patient time the contractions. (See Patient Education for description of timing contractions.)
If patient reports four or more contractions in an hour that last 45 to 60 seconds, have the patient get in a comfortable position and do the following:
Lie on left side.
Drink 1 quart of water.
Monitor contractions for 1 hour.
Call back immediately if symptoms worsen; otherwise, report in 1 hour.
If symptoms continue but do not worsen, the patient should be seen in 1 to 3 hours for evaluation.
If symptoms subside, advise the patient to rest for the remainder of the day and call in the morning to report how she is feeling.
STEP C: Backache Confined to One Part of Back, Relieved by Position Change
The patient may be experiencing nerve compression or muscle spasm.
Determine the area of pain and methods that relieve the discomfort.
Attempt to pinpoint conditions that may aggravate the discomfort (such as going up and down stairs, shifting gears in car, carrying infant).
Suggest appropriate substitutions for aggravating actions.
Encourage proper body mechanics.
Refer the patient to her primary care provider for a physical therapy referral, if indicated.
See Patient Education for general measures for relief of back pain.
STEP D: Backache Confined, Unrelieved by Position Change
Question the patient regarding the area of pain.
Record the frequency, duration, and severity of the pain.
After eliminating the possibility of uterine contractions, forward a message to the patient’s provider so the provider can act on the message within the hour.
STEP E: Backache Associated With Other Symptoms
Remember that diarrhea may be associated with preterm labor.
Question the patient regarding the frequency, duration, and severity of the pain.
Ask if the patient has a history of kidney stones, frequent urinary tract infections (UTIs), or sickle cell disease or is a carrier of sickle cell.
If the patient experiences pain on urination, unusually frequent urination, and has a backache described as “mild,” have her come into the office or clinic for a clean-caught urine culture.
If the patient is experiencing backache associated with flu-like symptoms, nausea, vomiting, or fever, she should be seen ASAP to evaluate for a kidney infection.
» Patient Education
Patients should be taught to monitor for contractions by doing the following:
Place your hands lightly on each side of your abdomen.
If your uterus tightens beneath your hands, you are contracting, whether or not you experience pain.
Time from the beginning of one contraction to the beginning of the next.
Time the length of the contraction as the amount of time your uterus feels tightened.
Call back if you are contracting four times or more in an hour, with contractions lasting 45 to 60 seconds; if symptoms rapidly escalate; if you are bleeding; if you are leaking fluid from the vagina; or if contractions are accompanied by bowel changes.
Some women experience more backache than do others. These women need help in establishing what is normal for them and need to feel confident they can call any time to report their symptoms.
General measures for increasing back comfort are as follows:
Practice good posture. Adjust as your center of gravity changes with the growing uterus.
Wear comfortable shoes.
Avoid standing for prolonged periods of time. Elevate one foot, if possible.
Sleep on a firm mattress.
Learn proper exercises for stretching back muscles.
2nd Trimester Bleeding
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STEP A: Abdominal Pain Associated With Vaginal Bleeding
A patient experiencing abdominal pain with vaginal bleeding needs to be seen ASAP in an appropriate facility. The patient should not drive herself. Transportation to the appropriate facility will depend on your location, the patient’s location, and the availability of necessary services.
If the patient meets your facility’s criteria for heavy bleeding, the patient needs to be seen ASAP, whether or not she is experiencing pain.
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