3rd Trimester Overview
Third trimester pregnancy complaints are common because of the pressure of the growing fetus on many body organs. Changes in the center of gravity, increasing venous compression, and difficulty sleeping are also attributable to the increase in uterine size and weight. Preexisting conditions, such as back problems, may be aggravated. During this time, patient thoughts may be dominated by a combination of growing excitement and apprehension in anticipation of labor and early child care responsibilities.
Several issues dominate telephone triage concerns at this point. The importance of continued fetal movement is one of those concerns. Many old wives’ tales exist about pregnancy, and perhaps one of the most insidious is that the baby should stop moving before labor. It is true that the nature of the perception of fetal movement may change as term approaches because of the growth and descent of the fetus, as well as increasing uterine tone, as labor draws near. All patients should have the expectation that the fetus will continue to move and should be educated to report the absence of movement.
Another dominant triage concern is the recognition of the onset of labor. Patients may have difficulty distinguishing between labor and normal 3rd trimester complaints. Symptoms of labor before 36 weeks’ gestation warrant immediate assessment. Symptoms experienced by multiparous patients may vary. Each facility should have a standard plan in place for evaluating patients for labor. Typical parameters for primiparous patients from 37 weeks’ gestation on are as follows:
Call when contractions are 5 minutes apart for an hour.
Call when membranes rupture.
Call if bleeding occurs.
Our facility’s standard for evaluating primiparous patients in labor is as follows:
_______________________________________________________________________________________________.
Multiparous patients often are advised to call when contractions are between 5 and 10 minutes apart for an hour, when membranes rupture, or at the onset of bloody show. Our facility’s standard for evaluating multiparous patients is as follows:
_______________________________________________________________________________________________.
It stands to reason that any patient experiencing symptoms with more pain than anticipated should be seen in person to be evaluated.
3rd Trimester Abdominal Pain
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STEP A: Symptoms Consistent With Contractions
If this patient is less than 36 weeks pregnant, she may be experiencing an onset of preterm labor.
Instruct the patient to time her 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 her 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 back in 1 hour.
If symptoms continue but do not worsen, the 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 patient is between 37 weeks pregnant and term, she may be going into labor. (See the protocol for 3rd Trimester Recognizing Labor.)
STEP B: Vaginal Bleeding Associated With Abdominal Pain
A patient 36 weeks pregnant or less who is bleeding heavily 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.
A patient 37 weeks to term who is bleeding heavily needs to be seen ASAP and should not drive herself. A patient who is bleeding lightly may be experiencing bloody show and may be going into labor. (See the protocol for 3rd Trimester Recognizing Labor.)
STEP C: Pain Confined to One Part of Abdomen, Relieved by Position Change
This patient may be experiencing pain caused by muscle spasm or fetal position.
Have the patient describe the location of the pain.
Reassure the patient it is not harmful to apply light counter pressure if it relieves pain that may be caused by fetal position or movement.
Advise the patient to avoid sudden position changes and support her abdomen when coughing.
Have her call back if symptoms increase particularly if she experiences right lower or upper quadrant pain.
If the pain is located in a region other than the abdomen but is relieved with position change, instruct the patient to monitor her symptoms and call back if the pain increases or is accompanied by other symptoms. If the 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 regarding the area of the pain.
Record the frequency, duration, and severity of the pain, particularly noting right upper quadrant pain.
Question the patient regarding any recent developing problems, such as pregnancy-induced hypertension (PIH) (high blood pressure, visual changes, nausea/vomiting, epigastric pain).
Forward a message to the patient’s care provider so that dispensation can be made within the hour.
STEP E: Pain Associated With Other Symptoms
Remember that diarrhea may be associated with preterm labor.
Appendicitis: If patient still has her appendix and the pain is in the right lower quadrant or if she is experiencing bowel changes, she should be seen ASAP or sent to an emergency room (ER) or urgent care center for an acute abdominal problem evaluation.
Gallbladder Attack: If the pain is located in the right upper quadrant or to the right of the sternum, particularly if the patient has a history of gallstones, or if the pain is associated with eating, the patient should be seen within 24 hours by her primary care provider or sooner if symptoms increase. Question the patient regarding new-onset severe indigestion.
Gastrointestinal Complaints: Bowel changes, nausea, or vomiting associated with malaise or other flu-like symptoms may indicate gastritis. The patient should make arrangements to see her primary care provider only after all preterm labor symptoms have been evaluated. The patient should call back if she cannot keep liquids down for 24 hours.
HELLP Syndrome: Sudden onset of pain in the area of the liver (right upper quadrant) may be associated with the development of preeclampsia. The patient may also complain of malaise, nausea/vomiting, or flu-like symptoms.
Urinary Tract Infection: If the patient experiences pain on urination or 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 or kidney stones.
» 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, each lasting 45 to 60 seconds; if symptoms rapidly escalate; if you are bleeding; if you are leaking fluid or any colored discharge 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.
3rd Trimester Anxiety and/or Depression
Anxiety may increase at the thought of impending labor. Women who have a history of anxiety surrounding medical procedures, such as phlebotomy, are more likely to experience great anxiety at this point. Panic attacks are particularly frightening at this point due to compromised respiratory efforts from the pressure of the uterus on the diaphragm and vena cava. Please review signs and symptoms of panic attack in the 1st Trimester Anxiety protocol in Chapter 8. Patients experiencing a panic attack at this point in pregnancy should be seen that day for further assessment.
» Key Questions
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STEP A: Anxiety in Late Pregnancy/Recognition and Treatment of Panic Attack
Research indicates that 4 out of 5 women experience some degree of ambivalence during pregnancy. Ambivalence normally subsides and fades by the 3rd trimester. However, it is not uncommon for women to have self-doubts about coping skills, integration of a new family member, or concerns about time for herself and her partner at this point in the pregnancy.
Even during a planned pregnancy, a woman may not feel totally sure about herself. Reassurance that feelings of inadequacy and of being overwhelmed are not uncommon at this point may be helpful.
Discussing the preparation for labor, delivery, and the early postpartum period may be helpful. Often, it is difficult for women to identify what makes them most anxious or concerned at this point.
Talking with a partner, significant other, close friend, or family member may be beneficial for some patients.
It may be helpful to talk to a counselor if concerns seem overwhelming or all consuming.
In our practice, we recommend the following counselors who may be of value in helping to sort out feelings during the 3rd trimester: __________________________________________.
A patient experiencing a panic attack in the 3rd trimester should be seen and evaluated either with a same-day appoint at her provider’s office or an emergency department (ED). She should not drive herself.
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 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 her to a mental health counselor within the next 3 to 5 days.
Reassure the patient that she may call back at any time if her symptoms worsen.
Your practice should have a system for identifying patients who are possibly at risk for depression during pregnancy.
In our practice, we do the following to identify patients at risk for depression during pregnancy (and thus, possible postpartum depression): _________________________________________.
Depression surfacing during the 3rd trimester is a red flag for postpartum depression!
STEP C: History of Depression or Mental Disorder
Patients with a history of depression or mental disorder may be at greater risk with a new pregnancy. Depression resurfacing during the 3rd trimester needs to be promptly addressed in these patients.
Follow the 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 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 it is not uncommon to have self-doubts during the 3rd trimester may reassure her that her thoughts are not abnormal.
Patients with a history of depression during pregnancy or the postpartum period need to be educated as to a possible recurrence and to be told help is available. Avoid being judgmental. Many patients have the misconception that all feelings can be controlled by will.
3rd Trimester Backache
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STEP A: Backache Accompanied by Possible Contractions
Determine if the patient is at home or at work. If she is at work, recommend that she go home but not drive herself. If she is at home, determine the location of her coach or other support person.
If symptoms occur before 36 weeks, the patient may be experiencing the onset of preterm labor:
Question the patient regarding any preexisting high-risk problems.
Question the patient regarding the presence of fetal movement.
Have the patient time the 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 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 back in 1 hour.
If the symptoms continue but do not worsen, the patient should be seen in 1 to 3 hours for evaluation unless she is at high-risk for preterm labor. In that case, she should come in to be evaluated ASAP.
If the 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 the symptoms occur from 37 weeks to term:
Question the patient regarding any preexisting high-risk pregnancy problems.
Question the patient regarding the presence of fetal movement.
Question the patient regarding previous instructions from her provider as to when to call if labor is suspected.
If the patient is primiparous:
Instruct her to monitor the contractions and call when they are 5 minutes apart for an hour, if her membranes rupture, or if she is bleeding.
If the patient is unusually uncomfortable or frightened, have her come in for an evaluation, even if she does not meet your criteria for early labor evaluation.
If the patient is multiparous:
Question the patient about prior pregnancies and the length of the last labor.
Instruct the patient that labor usually progresses more quickly after the first pregnancy.
If contractions are 5 to 10 minutes apart, if the membranes are ruptured, or if bloody show is present, have patient come in for an evaluation.
STEP B: Preexisting Back Condition
It is very common for preexisting back conditions to become aggravated during the 3rd trimester.
Determine the nature of the preexisting problem.
Ask the patient if 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 this pregnancy.
Refer to Patient Education.
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 the pain and methods that relieve discomfort.
Attempt to pinpoint conditions that may aggravate discomfort (such as going up and down stairs, shifting gears in a car, or carrying an infant).
Suggest appropriate treatments for aggravating symptoms.
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 the 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 that a dispensation can be made 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), sickle cell disease or is a carrier of the sickle cell trait.
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, each 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.
3. 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.
3rd Trimester Bleeding
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STEP A: Painless Vaginal Bleeding
Painless vaginal bleeding in the 3rd trimester is suggestive of placenta previa.
Ascertain if the patient has had a sonogram. If the answer is “no” or the sonogram cannot be located, schedule an appointment that day for the patient with a provider who can perform a sonogram to determine placental location.
Most patients with a previously documented previa in the 2nd trimester will be familiar with their placental location.
STEP B: Abdominal Pain Associated With Vaginal Bleeding
A pregnant patient who is not yet at 36 weeks and who is 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 pain is present.
If bleeding lightly, the patient still needs to be evaluated that day for the possibility of preterm labor or placental problems. Question the patient as to presence of contractions. If there is any question of preterm labor, the patient needs immediate evaluation.
If the patient is between 37 weeks to term and meets your facility’s requirement for heavy bleeding, she needs to be seen ASAP.
Light bleeding may be bloody show.
Refer to the protocol for 3rd Trimester Recognizing Labor.
STEP C: Vaginal Bleeding Associated With Pain, Itching, or Odor
The patient may have a vaginal infection. The patient should be seen that day for a wet mount and possible vaginal culture after it has been determined that she is not experiencing labor or placental problems.
» Patient Education
All patients should be told that any bleeding in the 3rd trimester should be reported immediately.
Patients who have had a sonogram should know the location of their placenta. Placenta previa or marginal placental localization is common in the 2nd trimester. Fortunately, most of these will resolve by early in the 3rd trimester. Most patients with a previous diagnosis of placenta previa will know their last sonogram results.
3rd Trimester Constipation
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STEP A: Pregnancy Related/Possibly Medication Induced
Constipation is a common complaint throughout pregnancy. Potential causes in the 3rd trimester include a continual hormonal effect, mechanical pressure, or a response to pain from hemorrhoids. Certain medications may contribute to pregnancy. Patients should be screened for this.
The following suggestions may be helpful:
Increase fiber in the diet.
Increase clear fluids by 1 to 2 quarts daily.
Add stool softeners as determined by office/clinic protocols. (See list of approved stool softeners.)
Increase exercise within the limits of 3rd trimester. Keep pulse rate below 140 beats/minute.
Change your prenatal vitamin to one with time-released iron or avoid iron supplementation.
Assess calcium needs. Many patients mistakenly take more calcium supplementation than is needed.
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