Well done, you’re almost there! The third trimester is the last stretch of pregnancy before your little one arrives. It’s a time usually characterized by both worry and excitement as your baby continues to grow, your baby bump becomes all the more significant and the birth gets closer.

From sleep to kicks, to back pain, and appointments, midwife and pediatric nurse Kara Manglani CNM, shares all you need to know about the third trimester, what merits medical attention, and what to expect during these final weeks of pregnancy.

Daniela: Good afternoon, Kara and welcome to Dreaming of Baby. We will today be discussing the third trimester, offering insight to moms-to-be on what they can expect during this time and how to best identify any issues which merit a medical professional’s attention. Before we start with our discussion, it would be great if you could introduce yourself to our readers.

Kara Manglani CNM: Hi Daniela, My name is Kara Manglani. I am a certified nurse-midwife in New York City.

Daniela: Great, thank you, Kara, to provide a good background to our readers on this stage of pregnancy: what characterizes the third trimester?

Kara Manglani CNM: Technically speaking, the third trimester is from the 28th week of pregnancy until delivery. In the third trimester, the baby is primarily growing. Women really begin to show in the third trimester. With all that growth can come a lot of muscular aches and pains. Emotionally, the third trimester is a time of extreme excitement and nervousness leading up to delivery.

Daniela: You mention muscular aches and pains as part and parcel with the third trimester. What can moms-to-be expect in this regard and how can they ease this discomfort?

Kara Manglani CNM: Each woman experiences muscular pains differently. This depends on various factors such as: if she has baseline back pain if this is her first pregnancy, her underlying abdominal musculature, and the position of the baby. Your ligaments relax in response to the hormones of pregnancy in order to compensate for the growing uterus. As the uterus grows, it can press against nerves causing pain. These pains are normal but can be extremely frustrating to deal with. I recommend periods of frequent rest. If you are on your feet all day, try to take regular breaks. If you are sitting at a desk all day, take breaks to elevate your feet. Also, practice proper body mechanics, such as bending at your knees and not your hips. Other relief measures can include a warm bath, warm compresses, acupuncture and physical therapy by someone experienced in helping with pregnancy-related back pain.

Daniela: Thank you for this overview, Kara. Are there any specific symptoms with regards to muscular and back pain moms-to-be must be on alert for and which may indicate an underlying – and more problematic – issue?

Kara Manglani CNM: Yes, probably the biggest concern would be preterm labor. Preterm labor can initially feel like back pain. This is especially so if the back pain comes and goes and is associated with abdominal cramping. If you are concerned you may be experiencing preterm labor it is important to see your provider right away. Another concern with back pain is a kidney infection. Warning signs of a kidney infection include a fever, nausea and difficulty or pain with urination.

Kara Manglani CNM: “If you are concerned you may be experiencing preterm labor it is important to see your provider right away”

Daniela: If a woman is soon due, would back pain be an indication that labor is approaching?

Kara Manglani CNM: It could be, but back pain can also be caused by so many other factors. If the back pain is accompanied by abdominal cramping, loss of the mucus plug, or your water breaking, it is a good sign that labor is approaching.

Normal weight gain in pregnancy

Daniela: Thanks for clarifying. You also noted that a woman starts to ‘show’ in the third trimester. In terms of weight gain, what’s normal for this stage of pregnancy?

Kara Manglani CNM: Normal weight gain is about 1 pound per week. This depends on the woman’s pre-pregnancy BMI. For a woman with a normal pre-pregnancy BMI her total weight gain should be 25-35 pounds with the majority of that weight gain occurring in the third trimester.

Kara Manglani CNM: “For a woman with a normal pre-pregnancy BMI her total weight gain should be 25-35 pounds with the majority of that weight gain occurring in the third trimester.”

Best sleep position in pregnancy

Daniela: Many moms-to-be note that sleep does not come much in the third trimester, is there anything they can do to overcome this? What would be the best sleep position?

Kara Manglani CNM: The best recommendation I have for sleep is the same recommendation I have for non-pregnant women. Good sleep hygiene. That means no screens an hour before bedtime, sleep in complete darkness and remove all sources of noise from your sleeping environment. Also, ensure that you are not drinking anything caffeinated close to bedtime. That includes caffeinated teas, sodas and sometimes even chocolate. Often the source of sleep issues is related to being anxious about delivery and/or frequent urination. In order to settle your brain, try reading a non-pregnancy related book before going to sleep. And for frequent urination, visit the bathroom right before bed and don’t drink anything an hour or two before bed. Hydration during pregnancy is extremely important, especially in the third trimester, but you can hold off right before bed. The best position and the position most women find to be most comfortable is lying on their side with the knees bent and a pillow between their legs. Many women prefer the use of a “noodle pillow” to find a position that feels most comfortable.

Daniela: Thank you for these tips. For the mom-to-be who does not find sleeping on her side comfortable, would other sleep positions still be healthy for baby?

Kara Manglani CNM: Recent research has proposed a link between sleeping on your back and stillbirth. So, I would recommend avoiding sleeping on your back. However, if you accidentally wake up on your back, don’t worry. As long as you feel the baby moving, the baby is fine. Sleeping on your side is recommended. Women find it very uncomfortable to sleep on their stomach in later pregnancy. I do believe they sell pillows specifically designed to help women who prefer to sleep on their stomach. Sleeping on your stomach with the use of these pillows to relieve pressure on your uterus is safe.

Daniela: You have mentioned fetal movement as an indication of a baby’s well-being. What does it mean if the baby is not moving, and what should a mom-to-be do if her baby is not moving.

Kara Manglani CNM: The most important predictor of fetal well-being (or how the baby is doing) is the baby’s movement. It is extremely important to pay attention to the baby’s movement every day starting at the beginning of the third trimester. There isn’t a specific number of times the baby should move a day. If you notice the baby is moving less than normal, or if the baby hasn’t moved in an hour, eat something, rest in a quiet room and count. If the baby moves less than 10 times in the hour, you need to go to the hospital right away. I mention this because so many times I meet women in the hospital who tell me the last time they felt their baby move was the night before. While most of the time the babies are completely fine, you never want to take that risk. You will never be wrong if you go to the hospital concerned that the baby is moving less than normal.

Kara Manglani CNM: “If you notice the baby is moving less than normal, or if the baby hasn’t moved in an hour, eat something, rest in a quiet room and count. If the baby moves less than 10 times in the hour, you need to go to the hospital right away.”

What to expect at your third-trimester appointments

Daniela: Thank you for clarifying, Kara. Based on your experience as a nurse-midwife, what can moms-to-be expect in their routine third-trimester appointments?

Kara Manglani CNM: First, we check blood pressure, to screen for signs of pre-eclampsia and gestational hypertension. We always listen to the baby’s heartbeat and measure the fundal height (the height of the belly). Then your midwife or doctor will try to feel for the position of the baby and get a sense of the size of the baby. This can be important for identifying a breech baby. Then we ask if the baby is moving, if there are any signs of labor (such as contractions or leaking fluid) and we ask about warning signs such as headaches, chest pain, and swollen feet. Depending on which week of pregnancy it is, we may do specific things. For example, around 28 weeks we recommend the Tdap vaccine for protection against pertussis or whooping cough. At 36 weeks, we swab for GBS bacteria. We always do some education. Whether that is breastfeeding, contraception, pain management of labor or education of signs of labor, there is always something we can teach you. And always, we answer questions. Your appointments are your opportunity to learn and ask questions, so I encourage women to come with a list of questions for every appointment.

Gestational Hypertension and Pre-eclampsia

Daniela: Great, thank you for this overview of what to expect at these appointments. You speak about pre-eclampsia and gestational hypertension. What is the difference between the two? Would they have the same symptoms?

Kara Manglani CNM: “Severe untreated pre-eclampsia can lead to eclampsia, which is the onset of life-threatening seizures. The only true cure for pre-eclampsia is delivery of the baby and placenta. Therefore, depending on the severity of pre-eclampsia, the woman may need to undergo induction resulting in preterm birth.”

Kara Manglani CNM: Gestational hypertension is hypertension that occurs after 20 weeks of pregnancy in a woman who previously had normal blood pressures. Pre-eclampsia is gestational hypertension plus protein in the urine. Pre-eclampsia is thought to be caused by abnormal placenta development. Pre-eclampsia is what used to be known as “toxemia of pregnancy”. Severe untreated pre-eclampsia can lead to eclampsia, which is the onset of life-threatening seizures. The only true cure for pre-eclampsia is delivery of the baby and placenta. Therefore, depending on the severity of pre-eclampsia, the woman may need to undergo induction resulting in preterm birth. Management of gestational hypertension depends on the severity of the blood pressures. Low range blood pressures can sometimes be managed as normal. Whereas very high range blood pressures may also indicate early delivery. The scary thing about pre-eclampsia and gestational hypertension is that they often present without any symptoms. Pre-eclampsia can sometimes be accompanied by chest pain, severe headache, visual changes and/or shortness of breath. If you experience any of these symptoms it is important to go to the hospital right away.

Daniela: Thank you for your time today, Kara!

Read more about fertility and pregnancy at Kara Manglani CNM’s blog, The Fertile Times.

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