Healthy Aging

With improved health care system and modern medicines people are living long.  People are working and learning new skills in later part of their lives.  Previously most lived a sedentary life after retirement from employment.  Of course, there are a lot more who have to work without retirement for ends to meet.  Here I am talking about those lucky ones who are employed by state or in reputed private sectors and have retirement with certain benefits and can lead a leisure life.

Yes.  After working tirelessly for long years to spend leisurely life is worth it.  But is sedentary life a happy life?  Retirement and sedentary life makes one feel the impact of biological age and boredom of inactivity leads to impassive life.  To have a happy and healthy post retirement life it is good to learn some new skill or start doing the activities one always felt like doing in younger days and could not due to pressures of family and its progress. 

Recently I had gone on a photo tour and met Ms. Aruna Berry.  She retired from state academic services few years ago.  On retirement her daughter presented her a DSLR camera and took her out for photo tours.  And now she is a passionate photographer and takes wonderful pictures.  She is also got trained for marathon races and often participates and wins.  I was very much impressed with her attitude towards life and being always bubbling with enthusiasm to learn new skills.  We had gone for Tiger’s nest monastery in Paro.  This is located at mountain cliff at 3,120M above Paro valley.  Most said that it will take at least 2-4hrs trekking up and coming down.  Aruna Berry along with her daughter and others took about 3hrs to reach and another two hours to come down.  I along with my husband took five hours to reach monastery and four hours to come down.  I understood her training for marathon races made her compete with youngsters. 

I have seen another woman who could easily be a septuagenarian at Arnold Arboretum in Boston.  She is working as tour guide here.  As she was guiding us through the important areas in the arboretum, she was moving so fast that it was difficult for me to keep pace with her.  Regular physical exercise makes one fit and healthy whatever is the age.

PC - Abhishek Singh, Professsioonal Photographer, Artist, Teacher

So whatever is the age one should strive to maintain physical fitness with good diet, physical exercise and healthy lifestyle to live happy and peaceful life till last breath.

Chattisgarh Tragedy

The tragic sterilisation camp at Bilaspur, Chattisgarh exposes the lacunae in our health care system.  In India sterilization camps are held at health centres at regular intervals.  The local health workers and the Primary health care centre are given target and not achieving the target may be punitive to the health personnel in-charge of the place.  To achieve the target local ANMs or Health Workers motivate eligible couples, particularly women to undergo sterilization / family planning / Tubectomy operation.  Special incentives are also announced for the candidates undergoing surgery in that particular camp. 

Generally the PHC doctors are trained to do these operations.  Laparoscopic sterilizations are done by specialists specially trained in Laparoscopic sterilization.  The camps are arranged in rural or semi-urban areas.  The candidates are motivated by the Health Workers.  PHC doctors arrange for all the material and medicines.  Few well trained specialist doctors are deputed to conduct surgeries on that day.  Deputed doctors will leave after the camp (surgery) is over and local PHC medical personnel will have to provide care for the patients for another 24 to 48 hours.  When everything is planned and executed well, and the facilities for the number of patients underwent surgery are adequate, serious complications and complaints are rare.  Only when the number exceeds the facilities available and medical personnel are inadequate or negligent complaints become innumerable and occasional complications arise.  Generally any inadvertent serious complication that has occurred is immediately recognised by the doctor and the patient will be immediately shifted to nearest higher centre where due care is taken. 

Every procedure has inherent risk.  All surgical procedures have risk of anaesthesia and inadvertent injury to the other organs and sensitivity to the drugs used in the post-operative period.   Female sterilization/Tubectomy, the procedure is intra-abdominal, wherein the abdomen is opened (laparotomy) or pierced with laparoscope, the possibility of injury to other abdominal organs will be present. This is rare in experienced hands.  Rarely when it happens in the inexperienced it can be recognised either during surgery or in the immediate postoperative period.  Causing injury is not negligence but failing to recognise it is considered as criminal negligence. 

The surgeries done at Bilaspur are by a very experienced surgeon who was awarded for his skills and service.  Laparoscopic tubal ligation is done by the experienced laparoscopist within five minutes.  Here the patient is kept ready and laparoscopist simply has to pass the laparoscope and pick loop of the fallopian tube and slip the rings to occlude the tubes.  For an experienced person who had done more than a lakh sterilizations to injure the organs even in one woman is remote possibility.  The death of 14 women is tragic and what exactly has caused the death should be investigated.   

It is reported in Hindustan times that deaths associated with female sterilization during the period 2003 – 2012 is 1434, an average of 12 per month.  Only appropriate medical statistics can bring out the exact number of deaths due to tubectomy per se or just associated cause. In one study in United States (1982 to 1988) has revealed that 4/100,000 women died due to sterilization and no man died for undergoing sterilization procedure and suffered any major complication.  The cost of the procedures is also 3-4 times more for women.  Though the incidence of serious complications  is negligible and mortality is almost nil in males due to sterilization procedure, in India, men are afraid of undergoing sterilization operation even though the incentives offered are double than that offered for women. In one year, April 2012 to March 2013, the total number of female sterilizations are 4.5 millions (45,00,000) and male sterilizations were 1,20,000. This is about 2% of sterilisation operations are vasectomies (male sterilisation operation) and rest 98% are tubectomies (female sterilisation operation).   It is generally women who are motivated to undergo sterilization.  The procedure of sterilization in male – vasectomy is a very simple procedure, less painful and without any serious complications and no mortality. The surgery is done by one small nick which may not require any suturing.  It can be safely done under local anaesthesia.  They can carry on normal activity within few hours of surgery. Their virility is not compromised.  They have to take precaution for three months against causing pregnancy.  Men should be encouraged more to undergo vasectomy which is a few minutes procedure requiring minimal anaethesia and minimal post operative care.

To reduce deaths due to sterilizations

 - Improve facilities at Primary Health Centres

 - Selections of cases should be done by specialist

 - Appoint adequate staff at the PHCs.  Expert care and transport facilities at higher centres should be available until all the patients are discharged in good condition.

 - When surgical procedures, particularly female sterilizations are taken up, the facility should have operation theatre to handle any emergency that needs immediate laparotomy and extended surgical procedure.  Even in case of male sterilization facility should be available to deal with any excessive bleeding or hematoma.

 - Targets should be feasible, not fulfilling should not be punitive

 - Sterilisations should be done regularly on fixed days, at least, twice a week

 -.If ever camps are held the maximum number of cases should be fixed depending upon the availability of beds and medical staff capable of handling the cases during and after the operation, until recovery.  Post operative care involves not only nursing care but appropriate antibiotics, analgesics and IV fluids.

 -  Reproductive health care and education should be part of health education in high school.

 - Spread awareness of simplicity of Vasectomy

 - Spread awareness of non surgical methods of contraception in males and females.

In this tragedy the government instead of arresting the doctor should do some introspection and try to improve infrastructure and formulate rules in conducting such massive sterilization camps in remote areas.

Third Gender

In my childhood whenever I saw eunuchs I would not understand why people looked down upon them or why they behave differently.  To me they look human, but dressing up differently and behaving in a peculiar way to extract money from people.  I could not understand the difference between the male, female and third gender.  As a child I was bothered why eunuchs are abandoned by parents and had to live in separate groups.  It would surprise me that parental love failed to accept the deviation in their children and support them to become better individuals. 

As a person with medical knowledge I always felt sorry for ‘hijras’ segregated from the society and becoming objects of ridicule. Various genetic and physical disorders are accepted as disease or deviation and persons are accepted in the mainstream life.  It is pathetic and inhuman that the genetic and physical variation resulting intersex individuals is not acceptable to the society.  Sex or gender identification depends mainly on

-         genetic structure of the individual

-         internal and external reproductive structure

-         hormonal conditions

-         social upbringing and gender role

The normal male genetic composition is 46XY, and female is 46XX. XX and XY are sex chromosomes which determine the sex of the individual. The development of male internal and external organs is active and depends on the presence of ‘Y’ chromosome in the genetic structure.  The absence of ‘Y’ leads to development of female external and internal organs.  In female the presence of 2^nd ‘X’ is essential for maintenance of ovaries.  A person with single X without Y or another X chromosome may apparently look like a female but will not have functioning ovaries and secondary sexual characters fail to develop in them.  These people are generally accepted as female and can lead a normal female life but will not able to reproduce.  Moreover, presence of X is linked to intelligence and absence of one X may become a cause for decreased intelligence. 

Because of genetic abnormalities the development of external genital organs may become impaired.  Sometimes due to congenital hormonal imbalance or certain drugs used by the pregnant woman can result in development of ambiguous external genital organs.  It may be obvious at the time of birth, sometimes later in life.  These persons are termed as intersex or hermaphrodites.  A true hermaphrodite will have ovaries (female gonads) and testes (male gonads).  True hermaphrodites are generally brought up as males.  But by puberty they may develop breasts and also start menstruating.  Depending on the choice of individual and social brought up, the person can change to either a complete male or female by the removal of ovaries or testes.  Based on this if there is any correctable abnormality of external genital organs is corrected by appropriate surgical procedure. 

Transgenders will be mostly of pseudo male or pseudo female hermaphrodites, depending on their genetic composition.  Person having XX will possess ovaries, but the external genitalia resemble more like a male due to hormonal imbalance.  In these person after correction of hormones, and necessary surgical treatment will make the person a female.  Persons having XY genetic composition having testes, but the body tissues not responding to testosterone hormone appropriately will not develop male genital organs and in some extreme cases may develop external female genital organs.  In these persons the gonads are removed and hormone supplementation is given and surgical correction to female genitalia is done. 

The variations in genetic composition of the individual are the cause for ‘normal’ male or female appearance to deviation on either side of gender can occur.  Like any other genetic abnormalities this gender deviation should also be considered as a variation in characteristics of human spectrum.  Transgenders or intersex persons must be considered as normal human beings and all rights, all human rights, bestowed by the constitution will be applicable to them.  The recognition of eunuchs as third gender by Supreme Court and passing  verdict on 15^th of this month has paved way for better future of ‘hijras’.   

I hope the society will understand the transgenders/intersex/eunuchs are part of human race and let them live a dignified life.  As soon as a child is born with ambiguous genitalia, a detailed investigation is carried and child is brought up as male or female depending on the genetic/gonadal and apparent external genital appearance.

The verdict of Supreme Court should make the government to take steps to bring them into mainstream with education and employment and help them live a dignified life.

Social upbringing and gender role is a psychological factor which may make a person feel a male or female.  Genetic, physical appearance and hormonal status is clearly defined in these individuals.  But psychologically they may feel different and may have different sexual orientation.  They do not come under intersex or transgenders and their problems are different.  They too should be respected as long as their orientation is not inhuman or against the principles of human rights.

Puerperium - Care after Delivery

Child birth is an important event in the life of a woman.  After the birth of a baby the woman is a mother and the change that brings in her life is for ever at fundamental level.  But medically speaking the changes that occur in a woman during pregnancy will return to almost prepregnancy level within 6-12 weeks.  This period is called puerperium.  For practical purposes this is limited to 6weeks period.  

A woman needs medical and family care during this period for restoration of physical and psychological normalcy.  For the woman who has become a first time mother needs good guidance and care to take care of her and the newborn.  The physical and physiological changes that occurred in the body of the woman will gradually return to pre-pregnancy state.  Immediately after childbirth, woman will have bleeding which may continue for 2-3 weeks.  Initially bleeding may be dark and thick, within a week it will be thin and pinkish and by third week it could be pale brownish yellow discharge.  Bleeding subsides usually by third week.  Occasionally it may continue off and on for another month.  Any time if the bleeding is felt to be excessive, woman should consult obstetrician.  Uterus which had accommodated the baby and placenta till delivery will gradually return to its original size of about fist.  By 6^th week it comes to its almost original non gravid size. 

All the changes that have occurred in heart, lungs, kidneys gastrointestinal and hormonal systems will come to non pregnant state. 

Changes in breast persist and help in milk secretion.  Milk secretion continues as long as the mother feeds the baby. 

The physical stress of labor and delivery may make woman worn out and new mother may take rest for few hours.  After the resting period she will start taking care of the newborn – start suckling the baby.  With the encouragement and help from family members and medical personnel she may as well feed the baby within an hour of delivery.

Various religions and ethnicities have different taboos that interfere with the recovery of woman after child birth.  When the delivery is a normal one, the woman should take bath regularly and keep herself clean.  Normal diet with increased proteins and fruits and lots of water is must.  Though heavy work is not allowed for 6weeks, woman should move about and take care of the newborn. Routine activities can be resumed after 6weeks of delivery.  Appropriate postnatal exercises can be taken up for restoration of body tone. Sexual activity can be resumed when woman feels comfortable and the perineal wounds if any healed well and there is no pain in the genital area or lower part of abdomen.  If sexual activity is resumed contraceptive practice also initiated.  A healthy woman can ovulate any time from 5^th week of delivery.

Puerperal care involves

-         care of perineal/ vaginal wounds

-         attention to any excessive or offensive vaginal bleeding

-         appropriate adequate nutrition

-         psychological support in emotionally stressed woman

-         watch out for any infection –genital, urinary or breast infection or infection of veins in legs

-         encouragement and guidance for breast feeding

-         Education about newborn care and immunisation and contraceptive practices.

The birth of a child turns a woman into a mother and her care makes a boy or girl a healthy citizen. 

“The hand that rocks the cradle rules the world”.

Woman

On 8^th March world celebrates international women’s day.  Though man and woman have important role to further human race towards progress, woman is not given due regard and never considered equal to man.  Man and woman are human.  They are equal as humans and differ as gender.  Nature has given the responsibility of carrying the human race forward to woman.  In this natural phenomenon the activity of woman becomes restricted, and responsibility increases.  The natural process of child bearing and child rearing has made woman the best domesticated animal by man.  The restricted activity and dependence during this period had made man to take a lead role in life and this continued for extended periods making woman a subordinate to man.  The domination of man on woman has led to abuse of woman in many ways.  Fulfillment of her human needs was controlled by man.

In the patriarchal society, woman dependent on man acts on behalf of man and as per the directions of man.  The birth of male is celebrated and male is provided utmost care.  The female offspring is given less importance and deprived of basic rights for dignified survival.  This is particularly common in present day in India.  The social bias to have a son is resulting in female feticide.  The skewed male female ratio in India is worrisome.  This will result in more social problems.  For a progressive society it is important the female population should be more.  Nature is strong supporter of woman and at birth the natural capacity of survival of female baby is more than a male baby.

The process of child birth involves risk to the life of woman.  Even in developed nations, though very low, there is mortality associated with child birth.  Nature balances this by appropriate male - female ratio.  Female birth should be encouraged and celebrated for the benefit and progress of human race.

Modern educated woman has proved herself in all fields moving ahead with man. Her knowledge of sexual and reproductive health care has lead to independent dignified life.  Health care is important for any person to live a healthy and happy life. The health of woman and children is the index of health of society.  It is a fact that anemia is common in women, particularly in the reproductive age group, even in developed countries.  In developing countries about 50% of women are anemic and in reproductive age group almost two thirds of them are anemic. 

Anemia is a condition where the oxygen carrying capacity of blood is decreased.  Hemoglobin, a protein in the blood binds oxygen in the lungs and carries it to the heart.  From there the oxygenated blood is pumped to all tissues in the body.  Hemoglobin releases oxygen in the tissues.  The normal hemoglobin in blood will be 13-15gm%.  In women it is generally on lower side, 13gm% is taken as normal.  Less than 10gm% is considered anemia.  This is manifested as general weakness, tiredness, and headache.  With severity of anemia the severity of symptoms and many others symptoms including frequent infections due to decreased immunity will develop.

In reproductive age group, if the woman becomes pregnant anemia increases all complications of pregnancy.  The incidence of fetal abnormalities and fetal mortality is more in anemic woman.  The important cause of maternal mortality in developing countries is bleeding in pregnancy/ delivery is more in anemic woman.  The incidence of infection, the second important cause maternal deaths is also high. So all women in reproductive age group must have Hb% done once in every year and if the percentage is less than 12gm% should consult a doctor and use appropriate medication.

The most important cause of anemia is nutritional deficiency anemia.  Iron deficiency is the commonest cause and vitamins – folic acid and B12 deficiencies are other contributing factors.  Proper diet and supplementation of iron and vitamins will improve the condition within a few months.  

In women of reproductive age group increased menstrual blood flow, frequent abortions or deliveries also can lead to anemia.  Reproductive health care and correction of menstrual loss with appropriate medication will help women to be healthy.

 All women, particularly in developing world, should get their hemoglobin percent test at the time of attaining puberty and repeat every year or as required, and maintain hemoglobin percent more than 12gm% always.  Fortification of salt with iron in addition to iodine will help to prevent anemia in women in our country.   

“Women’s health is nation’s wealth.”

Cancer - Don't Fear

-Scientific knowledge and progress in medical sciences has increased lifespan of humans worldwide.  Knowledge helped us to eradicate small pox in the world and recently our country is declared polio free.  Healthy life style can prolong life considerably.  But if health principles are not followed aged life can get burdensome with disease.

World over cancer incidence is increasing as people are adopting risky life styles.  According to the statistics by International Agency for Research on Cancer 14 million new cancer cases were added and 8.2 million died of cancer in 2012, where as in 2008 the number was 12.7 million and 7.6 million respectively.  It is estimated that this will rise to 21.6 million new cases and 13 million cancer deaths per year by 2030.  The study also found that there is increase in cancer in woman. 

Most common cancers worldwide are

-Lung cancer

-Breast cancer

-Colorectal (large intestine) cancer.

The cancers causing highest deaths are lung, stomach and liver.

All cancers afflict world population, but certain cancers are more common in some countries due to environmental and socio-cultural practices.  Cervical cancer is high in Columbia and low in Japan.  Stomach cancer is very common in Japan and low incidence in US. 

Cancer is caused by multiple factors. 

Tobacco consumption in any form – smoking or chewing is related to cancer of mouth, throat, lungs, esophagus, and also of bladder, pancreas and kidneys.  91% of oral cancers are directly related to use of tobacco.

Alcohol – excess intake is associated with esophagus and liver cancer.  Alcohol and tobacco have a synergistic effect in causing cancer.

Infections, particularly certain viruses are found to be associated with certain cancers.

-HPV – in cancer cervix, HIV- lymphoma, EBV in lymphoma and nasopharyngeal carcinoma, CMV in Kaposi’s sarcoma, Hepatitis B and C associated with liver cancer.

Dietary factors like smoked fish is linked to stomach cancer and excessive consumption of red meat and beef is related to intestinal cancer and high fatty diet is associated with breast cancer. 

Certain environmental and occupational factors like pollution, exposure to asbestos, arsenic, cadmium etc, exposure to pesticides and radiation are recognised as cancer causative agents. 

Genetic factor is known in woman having breast cancer.  A certain gene BR Ca 1 and BR Ca 2 inherited from mother predisposes woman to breast cancer and ovarian cancer.

In India the number of women suffering from cancer is higher than men.  It is also found that the cancer cases diagnosed in women is a million more in 2013 compared to that in 2012.  The increase in breast cancer is 20% and deaths due to cancer 14%. 

In India cervix (part of uterus) and breast cancer accounts for 60% of all cancers afflicting women.  

Prevention:  Certain cancers which are known to be caused be viruses can be prevented by vaccination. 

-HPV vaccine to prevent cervical cancer and hepatitis vaccine to prevent liver cancer caused by the virus.

-Avoiding early teenage sexual activity and multiple sexual partners and taking reproductive health care will bring down cancer cervix in woman.  Also breast feeding and low fat diet removes environmental causes resulting in breast cancer in woman.

-Abstaining from tobacco and restricting the alcohol consumption decreases the incidence of cancer, particularly lung cancer in men which is the cause of highest cancer deaths.

Screening:  Screening all woman who are sexually active for cancer cervix will bring down the incidence and deaths due to cancer cervix.

Screening for oral cancers in tobacco users also reduces the incidence of oral cancer.

Early diagnosis: Present day with availability of medicines and technology early diagnosis of cancer will result in cure.  Any person having the following conditions should immediately consult appropriate specialist and undergo evaluation.

-Persistent fever

-Unexplained loss of weight

-Change in the voice – hoarseness of voice, persistent cough

-Change in bowel habits, constipation and diarrhea alternating

-Impaired appetite

-Change in a mole or wart

-Any lump anywhere or any ulcer that does not heal

-Spit or vomit having blood or passing blood in stools, blood in urine

-Irregular menstrual bleeding or increased white discharge or thin blood stained watery discharge and post coital bleeding in woman

- Lump or hardness in the breast or retraction of the nipple in woman.

Cancers incidence can be reduced by healthy life style and clean environment, getting vaccinated that are available.  Those cancers that cannot be prevented if diagnosed early can be cured and will be compatible with healthy long life.

Pregnancy - Delivery-2

Conceiving and carrying on pregnancy for nine months smoothly is one part and delivery is the another part of safe outcome.  Gravida’s apprehensions increase as pregnancy progresses to term.  The fear of labour pains increases anxiety, sometimes cause difficulty in sleeping.  In the present day, under professional supervision delivery will be a smooth affair.  If the gravida is prepared what to expect at the time of delivery her co-operation will be more and tolerance to pain will increased.

Once the gravida has observed any of the symptoms of delivery she should immediately visit the doctor.  It is essential not to eat or drink before setting out to the hospital.  In pregnancy stomach emptying is slow and this further slows in anxiety and with labour pains.  If patient is on full stomach, and the condition demands emergency operation it may result in complications.  Even if the gravida continues in labour waiting for normal delivery she can have vomiting, causing inconvenience.  Also if gravida prefers analgesia or anesthesia for painless delivery it will be a difficult situation.  So once in labour gravida should not take any solid food, she can take sips of water or fruit juice, and follow the advice of the obstetrician.

The process of labour is divided into three stages.  The first stage of labour is the opening up of uterus (dilation of cervix) and descent of fetus into the pelvis (birth canal).  In the second stage the baby is born, and the expulsion of placenta (after birth) is the third stage. In general, in a normal case the process of labour takes 12 - 24 hours for the first delivery and gravida delivering 2^nd or later it will be 10 - 12 hrs.  Old text books say that a woman in labour should not see second sunrise.  But depending on the condition of gravida and fetus it may be prolonged for more than 24hrs.

Once the patient is having active labour pains, having pains once in 3-4 minutes and pain lasting for 40-50 seconds, and increasing gradually in frequency and duration will result in opening the passage of uterus and at the same time the fetus – head will slowly enters the birth canal.  With passing time there should be gradual progressive change in the passage and moving down of the fetus.  This is first stage which will be 6 – 18 hrs in first delivery and decreases in the later deliveries.  Once the passage opens up and head comes down low into the birth canal, the second stage of labour starts.  It takes 1-2 hrs for the birth of baby in first delivery and later deliveries it will take 30 minutes to an hour.  After the birth of the baby placenta will be expelled within 5 minutes.  It will not take more than half an hour.  This is same in first or later deliveries.

During the first stage of labour gravida should move about and can have small quantity of water or fruit juice.  If the labour is getting prolonged intravenous fluids are administered as per requirement.  Late in the first stage gravida will get confined to the bed.  When progressed to second stage she will be shifted to labour room or birth room and on to birthing table.  Woman who cannot tolerate pain can opt for analgesics in the early first stage and if facilities are available she can opt for epidural anaethesia.  Epidural anaethesia for vaginal delivery is not common practice even in metro cities and corporate hospitals in India.  

In the second stage the time of impending birth of baby, the labour pains are more frequent, once in every two minutes and pain lasting for more than a minute.  At this time gravida will have a strong urge to pass motion.  These are bearing down pains. With the bearing down pains and effort to push out will finally result in birth of baby.  Once the baby is out gravida feels relaxed. Obstetrician takes care of the baby, cleans eyes, clears throat and nostrils of the baby and hands it to the assisting staff.  By this time placenta is separated and expelled.  Obstetrician takes care to see that bleeding is minimal and examines for any injuries on the perineum or birth canal.  Any cut made in the perineum (area between the vagina and anus) to facilitate delivery and/or any injuries are sutured.  The parturient woman is cleaned and shifted on to her bed in post natal ward or room.  She is closely observed for another hour to watch for any excessive bleeding.  Later she will be under general nursing care. 

Woman who had endured pain for hours to give birth to a baby forgets everything in an hour and happily starts feeding it, and the bond between mother and child is strongest one on this earth.

Pregnancy - Delivery

The fetus and placenta are called as products of conception.  The expulsion of products of conception is known as delivery if it happens after 37 completed weeks and before that period it is called an abortion for all practical purposes.  If the delivery takes places after 28 completed weeks but before 37 completed weeks it is termed as premature delivery.  A term delivery is after 37 weeks and before 42 weeks of pregnancy.  After 42 weeks it is called post maturity. 

The expected date of delivery/confinement is calculated based on the first day of last menstrual period.  This is nine months plus one week or forty weeks or 280 days.  If a woman had her last menstrual period on 5^th January, her EDD will be 12^th of October. Applying this (Naegele’s) rule anybody can calculate their EDD.  This is applicable only when the woman has regular menstrual cycles. 

Early symptoms of impending delivery are

-Excessive mucoid discharge

-Passing of blood and mucus discharge

-Rhythmic backache and abdominal pain

-Watery discharge.

When any of these symptoms are present the gravida should immediately consult obstetrician and follow the advice.  When there is watery discharge, depending on the condition of fetus and mother delivery is planned.

In conditions of mucus or bloody mucus discharge obstetrician waits for spontaneous onset of labour pains if mother and fetus are normal.  The onset of labour pains may happen within 24hrs.

Many times labour starts with pain abdomen without any other premonitory symptoms.  Sometimes these pains could be false.  The pains occur occasionally for an hour or two and subside with rest.  This may happen more than once before the onset of true labour pains.  Gravida need not worry about it as long as her general condition is good and fetus is healthy and it is not more than 40 weeks of pregnancy.

True labour pains once set will not subside until delivery.  These pains are rhythmic occur initially once in every 5-10 minutes, gradually increase to once in every 2-3 minutes.  Duration of the pain also increases from 30-40 seconds to 60-90 seconds in the final stage of  birth of the fetus.  The severity of the pain also increases.  The pain usually starts in the back and extends from above the abdomen to low down.  The pain is like a wave starts mildly increases and then slowly subsides.  This repeats again and finally the baby is born and placenta is expelled.

There are techniques to make labour pains tolerable.  First and foremost is the tender loving care, and support of the loved ones. Understanding the process of labour and breathing exercises also help in tolerating pain.  Analgesics and anaethesia also be preferred for painless delivery.

However much gravida may experience pain, she forgets everything and smiles when she hears the cry of her newborn baby and want to hold it immediately.  The new life begins.

Pregnancy - Fetal movements

Once a woman is pregnant she keenly observes all the changes in her body.  Just after three months of pregnancy many worry about the size of their abdomen not increasing.  Usually, until three months are over there will be no apparent change in the abdomen.  The gravid uterus grows into the abdomen from 4^th month onwards.  Slowly there will be fullness or, if gravida is thin, bulge in the lower part of abdomen can be seen.  This slowly increases till 9^th month.  Later as the head enters the pelvis – birth canal the height of uterus may decrease slightly.  Any anxious gravida who conceives after infertility treatment can feel reassured by feeling the increase in the size of tummy.

The most important observation a gravida should have is of fetal movements.  Fetal movements are generally felt in the 5^th month of pregnancy (18-20^th week).  A sensitive gravida can perceive movement as early as 16^th week of pregnancy.  By 20 weeks they must be felt by the gravida.  The first perceived fetal movement is called ‘quickening’.  Once the movements are felt they have to be perceived well until delivery.  The perception of movements felt in the 5^th month gradually increases till 8^th month.  In the 9^th month the movements may not be as many as felt in 7^th and 8^th month.  There is slight decrease as the fetus settles down and head descends into the birth canal. 

In high risk pregnancy – where pregnancy is complicated by any other medical condition or pregnancy complication, gravida should observe fetal movements regularly.  Usually the fetus’ resting time is 15-20 minutes.  Fetus generally moves at least once in every 15-20 minutes.  In high risk pregnancy gravida is asked to keep a count on fetal movements every day – Daily Fetal Movement Count (DFMC).  Gravida is asked to count at least ten movements and note the time taken for the same.  Every day within that same period of time she should feel ten movements.  If time increases day after day fetal compromise is suspected. 

To count 10 movements may take more than two hours and it may be stressful to watch continuously for 2-3hrs.  I advise my clients to observe fetal movements for an hour - once immediately after waking up, again in the afternoon and before retiring to bed.  She should feel four movements in an hour, three is must.  The total movements felt in a day will be 10-12. If she cannot feel three movements she has to observe another hour and feel 3-4 movements.  Even in the second hour if she is unable to feel at least three movements she has to consult.  This is the way she can be assured of the fetal movements, and well being and consult obstetrician at earliest if she could not perceive movements as said.  This helps in decreasing sudden fetal deaths in late pregnancy.  This simple clinical follow up advice has helped me to save few babies at right time.

It is good that every gravida in late pregnancy keeps count of fetal movements and consult the obstetrician when the movements are not felt for more than two hours on observation.  

Pregnancy - Emergency Consultation

During the course of pregnancy a gravida consult

s obstetrician regularly as scheduled.  But sometimes there can be problems which necessitate the gravida to consult immediately.  The common problems which need to be attended to by the obstetrician are:

• Abdominal pain:  Any pain in the abdomen, particularly in the lower part, may be an early symptom of abortion or delivery.  There can also be other causes, first and foremost, the possibility of pain related to causes in pregnancy should be ruled out.  Some serious conditions in pregnancy which can compromise health of the mother and fetus also present with pain and may need hospitalization and appropriate management.
• Bleeding:  Any vaginal bleeding any time during the course of pregnancy needs immediate attention by the obstetrician.  The cause could be an impending abortion or delivery or certain serious conditions like bleeding from the placenta which is low down in the uterus or its premature separation.
• Watery discharge:  Breaking of bag of membranes which holds the fetus will cause sudden gush of watery discharge.  Some times it can be slow constant or occasional leak.  Depending on the duration of pregnancy and the amount of loss of fluid (amniotic fluid) treatment is instituted.
• Swelling of the body:  Sudden onset of swelling of feet, puffiness of face and stiffness of fingers could be due to increased blood pressure.  Early consultation with the obstetrician to identify the cause of swelling of the body will help in proper treatment to optimize maternal and fetal outcome in pregnancy.

• Severe headache, blurring of vision, pain in the upper part of the abdomen, vomiting, and convulsions could be presenting symptoms of high blood pressure which require immediate attention by the obstetrician.

These are important conditions when a gravida has to consult obstetrician earliest for better health of self and fetus.

Pregnancy - Diabetes Mellitus

November 14^th is the World Diabetes day.  In the present day of changed life style the incidence of Diabetes is increasing rapidly.  Asians, Indians in particular are more prone to diabetes because of their genetic constitution.  Along with diabetes there is also increase in diabetes in pregnant woman – gestational diabetes mellitus.

Diabetes in pregnancy could be two of types.  The woman who is diabetic has become pregnant or diabetes is diagnosed during pregnancy.  The diabetes which has its onset in the course of pregnancy will subside after delivery.  But these women are prone for diabetes in later life.  The risk factors for developing diabetes in pregnancy are:

• Ethnicity – Asians, Hispanics, Africans have more incidence.
• Diabetes in the family members – First degree relations.
• Obesity - over weight women.
• Age above 25 years.
• History of abortions, premature delivery, birth of overweight or underweight babies or abnormal babies in the previous pregnancies.

Gravida with any of the risk factors will have to undergo screening test for gestational diabetes mellitus (GDM). The obstetrician once recognises that a gravida is high risk for GDM will advise initial blood glucose test.  If this is normal – less than 100 mg% further screening test is done between 24 – 28 weeks (early in the 7^th month) of pregnancy.  The test is Glucose Challenge Test (GCT).  If this is normal further follow up test is done in the 9^th month.  If the result is abnormal another test Glucose Tolerance Test (GTT) is done.  Based on the report dietary suggestion, life style modification (exercise) and medication is instituted. 

Gestational diabetes complicating pregnancy is a high risk pregnancy, wherein the health of the fetus is affected adversely.   Certain complications of pregnancy like increased blood pressure – pre-eclampsia, premature delivery may increase. The chance of baby being large or of low birth weight is high.  This makes normal delivery difficult so operative delivery may required.  The possibility of still births and neonatal complications like respiratory disease or certain metabolic disturbances may also increase.  

Team management including physician, obstetrician, dietician and paediatrician will result in successful out come, healthy mother and baby.

In women who are diabetic and become pregnant the incidence of morning sickness, abortion, premature delivery, pre-eclampsia, very low birth weight or overweight baby, congenital malformations, still births and postnatal health problems to the baby will be high.  In these women early scans can help in diagnosing abnormal fetus.  When blood glucose levels are monitored and proper diabetic control is done fetal health will be improved. 

In the present day women are career oriented and marriage and child birth is being delayed to the third  decade.  These women should maintain healthy life style.  A healthy woman will give birth to healthy baby.

Pregnancy - Medicines

Pregnancy being a special condition, every pregnant woman takes special precaution in all her activities.  Gravida becomes cautious in what she eats and drinks.  Special precaution should be exercised even while using medicines during the course of pregnancy and breast feeding period.  Certain medicines and infections will have harmful effects on the fetus.  They can cause various system abnormalities and anatomical defects.  The period of pregnancy from day 31 to 71 is critical for differentiation and development of fetus.  Some drugs can have impact on the development of embryo-fetus, resulting in abnormalities.

A healthy gravida is advised simple folic acid tablets in the first three months of pregnancy.  This will help in the reduction of certain nervous system abnormalities.   After 4^th month iron and folic acid tablets are started and continued till 9^th month or delivery depending on the health of the gravida.  As more than 50% women are anemic in our country, ICMR recommends 60 mg of elemental with 500 mcg of folic acid for 100 days to all pregnant women.  A poorly nourished gravida not taking balanced diet is also recommended to take supplementation of all other vitamins and minerals especially calcium.  

Any other medication in pregnancy is taken only on specific indication.  A gravida suffering from any medical disorder like high blood pressure, diabetes or epilepsy has to continue according to the advice of the physician.  If the gravida develops any other serious illness like typhoid, malaria, urinary infection etc, should use medicines appropriate to the condition.  She should inform the physician of her pregnancy and its duration.  Even high temperature itself may be harmful to fetus and gravida.  So when any illness that is harmful to mother and fetus, as far as possible medications are given as not to harm the fetus.  When gravida’s condition is serious priority is given to the gravida and fetus then becomes secondary. 

Even during the course of pregnancy when the gravida has any abnormal bleeding or possibility of premature delivery hormonal treatment is given.  

Immunisation against tetanus is routinely practiced in our country.  Two T.T. injections are given in the 5^th and 6^th month in first pregnancy and from second pregnancy single dose is advised in the 8^th or 9^th month of pregnancy. 

Any pregnant woman should be cautious in using self medication, using medicines (other than folic acid) particularly in early pregnancy, the period of organ formation, is avoided

In short a healthy gravida taking a balanced diet does not need any medication other than iron supplementation.

Pregnancy - Investigations

Antenatal checkups help gravida to give birth to healthy baby.  The aim of antenatal checkups is to evaluate the health of woman and recognise any medical or surgical

condition that can have adverse effect on the outcome of pregnancy.

In the first visit obstetrician not only confirms pregnancy but also evaluates the woman by taking her personal, family history and appropriate blood and urine examinations.  General health checkup includes total physical examination and recording height and weight of the gravida.  Common investigations in the first visit are,

Blood examination:  most importantly to know the hemoglobin percent, blood grouping and Rh typing, also for any sexually transmitted diseases, and serum hepatitis. In regions where hypothyroidism is endemic thyroid hormone test is done.  Few more tests are done depending on the gravida’s medical history.

Urine examination:   for any infection.

If the gravida is having Rh negative blood group, husband’s blood grouping and Rh typing is done to take appropriate precautions if the husband is Rh positive.  If the gravida is positive for any sexually transmitted diseases, spouse also evaluated for the same and the couple treated to prevent any complications to the fetus.

First visit:  confirmation of pregnancy, height and weight, blood pressure recording, blood and urine examination, if necessary ultrasound scanning. 

In developed countries Pap smear test is done as a screening procedure for cancer cervix.

In consecutive visits and every visit

Weight, blood pressure, fetal growth (height of uterus) is noted.  Any complaints by the gravida are addressed to.  The total weight gain in pregnancy in a normal healthy woman, with a healthy pregnancy is 10-12 Kg.  Increase in weight by 1/2 Kg a week after 16 weeks of pregnancy is expected.  Underweight woman is encouraged to gain more weight and obese to restrict total pregnancy weight gain to 6-8 Kg only.  

Blood test for hemoglobin percent and urine for any sugar and proteins is done.

If family history of diabetes mellitus is present the gravida needs to undergo test for blood sugar at 20 weeks, 28 weeks and repeated at appropriate intervals if necessary.

Rh negative group woman with Rh positive husband will have to undergo blood test (Coomb’s test) at 20 weeks, 28 weeks and 36 weeks to note any changes in the blood that may adversely affect the fetus.

Woman with hypothyroidism may have to undergo repeat test for thyroid evaluation for adjusting the dose of thyroxin hormone.

Ultrasound scanning is done early in pregnancy to confirm viable pregnancy and for dating, between 12-14^th week and around 18 - 22 weeks to rule out any fetal anomalies.   Scanning may be repeated if there are any problems affecting the growth of the fetus and evaluation of fetal growth.

Any illnesses occurring during the pregnancy will need appropriate tests.

In India gravida is given all the reports of investigations.  She has to carry all these when she visits the obstetrician.  If the clinic or hospital gives a record of all the investigations with the history and examination of woman she should carry this to her consultant at every visit to record findings.  This will help in early identification of any risk arising during the course of pregnancy.

Good antenatal care will ensure healthy mother and healthy baby.

Pregnancy - Antenatal Checkups

More than a century ago, a woman consulted the doctor once to confirm pregnancy and later at the time of delivery.  Pregnancy care and antenatal checkups (checkups during the course of pregnancy) in pregnancy have started about a century ago.  In the early 20^th century the nurses of Instructive Nursing association, Boston, had started visiting women registered for delivery at Boston Lying-in Hospital.  The dramatic improvements in the health of the newborn and mother laid foundation to the regular antenatal checkups and special care during and after delivery.

Presently a pregnant woman consults doctor (obstetrician) a week or two after the missed period till three months after delivery – totally for about one year she will be under the care of obstetrician.  Checkups in pregnancy can be categorized as – antenatal checkups or antenatal care, intranatal care – at the time of delivery and postnatal checkups/care in the following three months after delivery.

The aim of regular checkups in pregnancy is to recognise high risk pregnancy and take appropriate care to minimize complications to mother and fetus.

Obstetricians date the pregnancy in weeks.  The normal duration of pregnancy is 40 weeks from the day of first day of last menstrual period.  The first 14 weeks is termed first trimester, later upto 28 weeks is called second trimester and the last 12 weeks is the  third trimester.  The regular checkups are advised once in 4 weeks until 28 weeks, after 28 weeks till 36 weeks - once in 2 weeks and after that weekly until delivery.  After delivery, the woman should have at least two postnatal checkups, once after three weeks of delivery later in the 12th week.

  In general gravida should undergo monthly checkups till 7^th month, fortnightly till ninth month and weekly until delivery.  If the gravida has any risk associated with pregnancy she will have to visit more frequently, as advised by the obstetrician. 

In India, or any other developing country for various reasons gravida may not be visiting the obstetrician regularly.  If the woman is healthy, and has no risk factor, with the advice of the obstetrician she can cut down her visits.  A minimum of four checkups during the course of pregnancy will help to safeguard the health of gravida.  These should be once to confirm pregnancy in first three months, 2^nd visit in the fifth month, third in the 7^th month and 4^th in the ninth month.  If the gravida does not deliver in 15days she should again have another checkup.  If any risk factor is noticed during these checkups the gravida will be advised consultations accordingly.

I generally advise/persuade rural woman who are averse and ignorant of health care in pregnancy to, at least, have four antenatal checkups, use iron tablets for three months, two tetanus toxoid injections, a day admission for delivery in the hospital.  Following this simple principle will help to reduce maternal and fetal mortality and morbidity to a great extent.

Changes in Pregnancy

 Pregnancy is a natural process.  But it is a special condition which needs due care to have best outcome.  Various changes occur in the body during the course of pregnancy, delivery and lactational period.  All these changes in the woman help growth of the fetus and newborn. 

Some changes are obvious and external and some may present as symptoms in pregnancy.  As the fetus grows, the abdominal girth increases, becomes maximum by ninth month.

Enlargement of the abdomen is more obvious after 5^th month.  In the initial phase there is increase or fullness noted in the lower abdomen as the uterus grows and starts entering abdomen from below (pelvis).  Increasing size of the abdomen after 7^th month may result in stretch marks and their pigmentation.  The stretch marks are due to stretching of the abdominal skin beyond its elasticity.  Stretch marks may not appear in all women.  The protuberant abdomen may result in change postural change to maintain balance.  Also the changes in the pelvic joints preparatory to delivery may result backache.   

As the urinary bladder is close to the uterus, along with uterus the urinary bladder gets upward displacement.  In the last few weeks of pregnancy, in thin woman, urinary bladder when filled can be seen as a bulge in the lower part of abdomen.

The size of the breasts also increases, areola darkens, and small tubercles are seen on the areola.  Veins may become prominent and stretch of breast skin may result in stretch marks and they may be pigmented.  Sometimes there can be thin, watery secretion from the nipples after 5^th month. 

Apart from these external changes there are internal changes in the body.  The apparent increase in salivation is due to nausea resulting in failure to swallow it.  Sometimes gums may be swollen and bleeding from them can occur at the time of brushing.  The hormonal changes in pregnancy results changes in the stomach.  After a meal stomach takes more time to get emptied.  Some woman may experience acidity problem.  Slow movement of food in the stomach and intestines will cause more absorption of water and constipation is a common problem in pregnancy. 

The most important changes that occur are in the heart and blood circulation.  Heart has to supply blood to uterus to sustain the growing fetus.  It has to pump more blood per beat and number of beats increases as the pregnancy advances.  The increase in heart rate will be 15/min than non-pregnant state. The blood volume also increases and by term, it could be almost 50%.  The coagulability of the blood also increases.  These changes help in tolerating and limiting blood loss at the time of delivery.  

The changes in kidneys will help in clearing the waste products of increased metabolism in the body.  The efficiency of kidney increases. 

There are also changes in the lungs.  The increase in the size of uterus and becoming abdominal organ pushes the diaphragm upwards.  The respiratory rate increases per minute.  Woman may sometimes feel breathing laborious. 

To sustain growth of fetus and increasing metabolic process of the pregnancy there are insidious changes in the metabolism of carbohydrates, proteins and fats. 

All pregnant women gain weight.  The increase in weight is not just because of the fetus and placenta or increased size of the uterus but also increased maternal weight.

A healthy woman tolerates all these changes and will have successful outcome.

All the changes that occur in pregnancy will revert to normal by the end of three months after delivery.  

Pregnancy - Common Complaints - 2

Urinary frequency:  Early in pregnancy and in the last few weeks of pregnancy gravida may complain of increased frequency of urination.  This is because of growing uterus in early stage and head of the fetus causing pressure on the urinary bladder at later stage.  At any stage if the frequency is associated with painful urination, investigation is done to rule out or confirm urinary tract infection and if necessary appropriate antibiotic treatment is instituted.

Lower Abdomen Pain:  In early pregnancy there can be dull occasional lower abdominal pain due to stretching of ligament of the uterus.  This pain can be more on the right side.  If pain is intolerable simple local heat or plain paracetamol tablet will relieve it. 

Backache:  It is another common complaint which increases with period of pregnancy.  Proper maintenance of posture and using appropriate footwear will  help in relieving pain.  Avoiding excessive weight gain and back strengthening exercises will also be helpful.

Fever:  Many times a woman with missed periods consults family physician complaining of fever.  But in fact, it is not fever in its true sense, but increased warmth in the body due to hormonal changes in early pregnancy.  The temperature when recorded will always be below 99.5*F.  Explanation to the woman is sufficient.  If the temperature is 100*F, and patient is having any other complaints, appropriate investigations are done and treatment is given.

Breast Pain:  Pregnancy induces changes in the breast.  The size of the breast increases.  Gravida can also develop small tubercles on the areala.  It may become painful to touch.  After 5^th month some women may have watery discharge from the breast. 

Giddiness:  It can occur in early pregnancy due inadequate diet or later pregnancy when the uterus compresses large blood vessels when gravida stands for prolonged periods.  When there is feeling of giddiness, gravida should immediately lie down on her left.  This immediately clears the blackout.

Swelling of the feet:  generally occurs in the later half of pregnancy, most commonly in the the ninth month.  This is due to pressure of uterus on the blood vessels.  This will subside with rest, lying on the left side.  Swelling of the face or hands need special attention.

Pigmentation:  Many women may have darkening of the skin on the face (chloasma) , nipple and areola,  in the midline of abdomen.  This is again due to hormonal changes in pregnancy.  This usually occurs after 4^th month.  Exposure to sunlight may increase darkening on the face.

Stretch Marks:  This occurs in the latter third of pregnancy.  Stretch marks occurs on the abdomen due to increasing size of uterus causing stretch on the abdominal wall.  The stretch marks also can occur on the breasts.  These stretch marks can be lighter shade or may get darkened.

In general there are some complaints, which are symptoms of  pregnancy, usually more than 80% woman will tolerate all the physiological symptoms with assurance or minimal medication.    

Pregnancy - Common Complaints - 1

Young married woman who misses her regular menstrual period will suspect pregnancy.  Since the day of missed periods she will be having many doubts.  In a joint family mother-in-law or other elders will guide her or reassure her for certain routine problems.

The common complaints in pregnancy are

Nausea and vomiting:  (Morning Sickness)  More than 50% of women may have this complaint in various degrees.  Some may have occasional nausea or vomiting while others have persistent nausea which may continue rarely till delivery.  Most of the time, it will subside by the completion of third month.  Even vomiting in pregnancy, though troublesome in first three months, may continue in a lesser degree, rarely, to term.    

Indians have a habit to tickle the throat at the time of brushing teeth in the morning and bringing out all the contents of stomach.  Usually the stomach is empty in normal condition.  In pregnancy due to physiological changes the stomach emptying is delayed and there may be some digestive fluids in the stomach.  At the time of brushing and cleansing process when throat is tickled, this fluid, white or light yellowish or greenish sour fluid, is vomited out.  This is of no consequence.  The woman should stop this forcible vomiting.

Minor degrees of nausea and vomiting may respond with counseling, reassurance, change in diet with easily digestible nonspicy foods.  Sometimes gravida (pregnant woman) may

have intolerance to certain odours and sight of certain foods.  The sight and odour of the food itself induces nausea and vomiting.  In such conditions it is best to avoid such foods.  When nausea and vomiting are interfering with nutrition of the patient, simple medication like doxylamine succinate with pyridoxine tablet is advised.  If persistent, more powerful pregnancy safe anti-emetic like phenergan tablets will be administered.  Rarely a gravida may have persistent vomiting and will be unable to retain anything taken orally resulting in deterioration of health.  In such conditions she is hospitalized and parenteral treatment is initiated.  Gravida should be investigated for her health status and to rule out any obstetric or medical condition resulting in intolerable vomiting – Hyperemesis gravidarum.  Correction of electrolyte balance and IV fluid administration and anti-emetic inject:ions will generally restore the health of the woman.  Usually nausea and vomiting will subside and general appetite is restored by 12^th to 14^th week of pregnancy.

 Excessive Salivation: Sometimes woman may have excessive salivation - always wanting to spit. This will subside by the end of third month.  Rarely medication is required.   

Heart Burn: Some women may also have heartburn – burning pain in the middle of the chest.  For relief of this gravida is advised not to lie down immediately after taking food.  Avoiding spicy foods and eating curds or drinking buttermilk can reduce the symptom to a great extent.  After having food it is better to be in reclined position for some time than to lie down.  In occasional cases antacid liquid may be used.

As the pregnancy progresses some women may feel fullness with small quantity of food.  In such condition she should have frequent meals in small quantities. 

Constipation: Another significant problem in pregnancy is constipation.  This may become the cause of manifestation of piles – bleeding with defecation.  Constipation can be corrected by taking foods having more fibre – vegetables and fruits and drinking plenty of water. 

                                                                                                    ......contd

Early Pregnancy

Procreation is one of the fundamental desires of a living being.  Every person would like to have children of his/her own.  In a happy marriage pregnancy is a celebration.  This is a step towards firm establishment of a family.

 

In a healthy couple the chance of conception is 60-70% within 6 months, about 80% conceive within one year and another 10% within 2 years.  Couple not using any contraception and do not conceive within 2 years need evaluation.

The first indication of pregnancy is failure to have menses in a regularly menstruating woman.  Within a week of missing period, pregnancy can be confirmed by any home pregnancy test.  As days pass by woman may have impaired appetite, nausea, sometimes occasional vomiting.  This is the time when woman consults obstetrician. 

In the early pregnancy a visit to the obstetrician helps in basic health evaluation of the woman.  In a healthy woman in the first 3 months of pregnancy the only medication that is advised is folic acid tablets.  This will reduce the incidence of certain abnormalities in the fetus, central nervous system in particular.  If the nausea and vomiting are not bothersome no medication is necessary.  Nausea and vomiting are generally more in the mornings, hence morning sickness.  This can be overcome by reassurance, taking small frequent feeds, avoiding spicy foods and long hours of starvation and also starting the day with eating than drinking coffee or tea or milk. Milk is preferred as it is healthier than tea or coffee.  If the nausea and vomiting are persistent resulting in starvation and dehydration in woman, medication is advised.  This is usually a combination of pyridoxine – a vitamin and doxylamine tablet.  It is taken twice or once daily depending on the preparation.

The first three months of pregnancy (first trimester) is critical for the development of the fetus. This is the time when all the organs are formed.  This is the time when certain medicines, infections and radiation can cause a disturbance in the organogenesis that can lead to minor or major malformations in fetus.  Any medication during this time is taken under proper guidance only. 

A healthy woman needs one checkup in the first three months of pregnancy.  A healthy woman can carry out her regular activities.  Women who are doing manual labour or strenuous work or getting exposed to chemicals or radiation should avoid it.  Pregnant woman can carry on her physical activity as long as she is comfortable. 

Pregnancy in general a physiological condition and initiates certain changes in the body that continue during the course of pregnancy.  With the support of the family and under the guidance of obstetrician woman will adjust to all changes and will have a successful and happy outcome. 

Experience

This has happened in early eighties.  There is a village, 15KM from a second grade Indian town.  The town bus makes two trips, one in the morning and other in the evening.  The village did not have a qualified medical practitioner until Dr. Sujay had started his clinic.  Coming from a poor family, pressurized to earn Sujay opted to practice in the village so that he can serve and settle down in practice early.  He was welcomed by villagers who were until then were treated by RMP (quack). 

Sujay had to start his clinic in single room.  This is ‘L’ shaped room.  Those days disposable syringes were not known.  Glassvan (glass) syringes were used.  These syringes after use are washed and reused after sterilization by autoclaving (big hospitals) or simply boiling (clinics).  Dr. Sujay had kerosene stove on which he would boil the syringes and wash them with boiling water and reuse after boiling. The doctor has arranged his table and chair in front of entrance.  This would give him a chance of having view of the street and people walking could also see the doctor and inform villagers about his presence.  The doctor stayed for five hours – 9AM to 2PM.  This was extended when patients continued to come.  After 2PM, after the last patient, he simply put down the stove, takes his bag and buzz out to home in the town.

In the clinic there are two benches for patients to sit, if somebody is too weak, they can as well lie down and others would adjust on a single bench or sit down on the floor.  Sujay started his clinic immediately after internship.  He was young, friendly and considerate.  This had made him dear to the villagers.  Many would come tell their complaints and take tablets for relief.  For this they never paid.  In the village practice, doctor is paid only if an injection is given.  Examining the patient and writing down prescription means nothing.  It does not deserve any payment.  Even now this practice continues in villages.

On that eventful day, as usual, Sujay had come to his clinic, all the way greeting villagers, young and old.  People who are waiting told him “doctor I will come after half an hour or I will bring my ---- you will be there no”, and moved along.  By the time he reached his clinic the owner of the room cleaned it and made the patients sit.  She often sits there and watches doctor do his work, chit chats with patients and comforts them with soothing words. She is a widow, aged about 50 years and lives separately from her only son living in the immediate neighborhood. 

As the doctor came in, people started talking.

“What doctor, today you are late”

“I am waiting here for past one hour.  I am the first to come.  So see me first”

“My son has high fever; he did not go to school, please see him soon and send”

Hearing all this Sujay had lighted the stove.  Put the vessel with water on it.  Put few syringes in it to boil.  He adjusted things and medicines in various boxes on his table, took out his stethoscope and BP apparatus, hung the stethoscope around his neck.  As he was doing all this he was responding to patients talk.

“Now, now don’t worry, just two minutes.  I will see you all fast, write good medicines.  Let the water boil.  I can give injections.  Raju missed his school, I will give him injection he will attend school.  Now it’s over.  You said you have come first.  Come on sit here on this stool”.  The stool is just beside his chair.  Behind him is table with stove and syringes boiling.

He examined him gave him some tablets and told how to use.  He asked him to swallow one of the tablets (to observe any allergic reaction) and sit until syringes are boiled.  Then one after other he was examining patients, giving injection and some tablets; sometimes giving tablets to the accompanying person also who complained of symptoms and asked for tablets, refusing any examination to avoid fee, and take tablets one or two freely.

“Saar, I have body aches, give yellow injection.   It works well for me”, Rajaiah a labourer and alcoholic who frequently visits doctor came and dictated his treatment. 

“O Rajaiah, why don’t you stop drinking that arrack?  You need not come to me for these injections.  Instead you can eat eggs or mutton.”  Sujay said as he was examining another patient.

“Saar, I work whole day.  Without arrack I can’t sleep.  Give some tablets for numbness in my limbs”.

 “OK, sit.  Let me see these patients who have come already”.

“Arey Sheenu, what happened to you”, Rajaiah asked a youngster who was already sitting there.  He also sat on the other side of a bench where there was some place to sit.

“I am having fever for the past two days uncle.  RMP Chandranna gave two injections yesterday and day before.  No effect.  So I came to Sujay doctor”.

“Arey what Chandranna knows is nothing.  This Saar is really good.  He has healing touch.  You take one injection.  Next day you will run.”

Sheenu or Srinivas is young man who has studied till 5^th class and took up agriculture.  He generally visits village quack who is his friend.  When that treatment doesn’t work he will visit other doctors.  Now he was suffering from cough and fever. When it was his turn he went and sat on the stool by the side of the doctor.

“So your name is Sheenu, I think it is Srinivas, what is your age”

“22years sir.  I am having fever sir.  Cough is really troubling me.  Give me something that works fast.”

 The patient was coughing without covering his mouth, droplets polluting entire room.  Sujay turned the patients head to a side and auscultated his chest.  He could understand the severity of infection.  He decided to give antibiotic injection.

In those days penicillin was regarded as panacea for all infections.  It was really a wonder drug.  The main draw back is the serious allergic reactions, sometimes killing the patient instantly.  Whenever penicillin is given, history is taken, whether patient had taken penicillin injection previously.  If they had taken it was given, otherwise when it was essential to give penicillin injection, a test dose is given to know allergy.  If the patient tolerated, it was given.  Sujay asked, “Sheenu did you take penicillin injection previously?”

“Yes sir.  I took it”.

“OK.  Then I will give you that”.

Sujay loaded penicillin in a syringe and gave it into arm. He withdrew the needle and was about to wash the syringe with boiling water.  Just then the boy slumped. 

Sujay left the syringe on the table and bent down to lift the boy. 

“Hey, what happened?  Please you all get up from this bench.  Help me let the boy lay on the table.  Allow some fresh air.  Just move away”.

Sujay understood that it was allergic reaction to penicillin.  He was thinking, talking and doing everything he can and should do.  Patients pulse was feeble and patient was unconscious. Sujay’s pulse was bounding, he could hear his heart beat, instead of lub dub it was just dub dub thumping.  He put a book under the legs of the patient.  With shaking hands he gave corticosteroid injection intravenously as another patient Rajaiah helped him.  He asked another accompanying person to open the IVset from its cover as he took out the saline bottle and fixed the set and connected to the needle already in the vein by giving injection.  He hung the bottle to a nail on the wall.  He watched the pulse again.  It was still feeble and patient appeared unconscious breathing laboriously.  He took the adrenaline vial took 1/2cc of it and diluted with distilled water and gave 1/2cc  subcutaneously.  Watched pulse again.  Patient’s breathing was slowly getting normalised.  He checked the BP.  It was very low.   He again repeated another dose of adrenaline.  Increasing the flow of saline flowing, Sujay wet with sweating once again looked for pulse, though it was fast it was feeling better, BP near recording normal, and Sheenu breathing normally. 

People on the road also came in and started talking,

“What happened?  Injection reaction?”

“Patient will live or die?  Don’t leave the doctor.”

“Doctors are commercial, they just want to give injection and take money, don’t have any service motto.”

“This doctor is good.  He gives injection only when required.  He treated so many serious conditions.”

People talked as they liked.  Rajaiah was trying to help the doctor as asked.  He was doing his best in helping the doctor. 

“Saar asked him whether he had taken injection and then only gave it.  It is not his fault.”

As all this was going Sheenu gained consciousness. 

“Eyy, Sheenu how are you feeling?”  Sujay asked on seeing Sheenu opening his eyes.  He once again checked the condition of patient and knew that the crisis was over.  He gained some confidence, and asked people surrounding to move away and allow fresh air.  He said the boy is fine to all and asked them to move out.  In another 15-20 minutes everything had become normal.  IV fluid was almost over.  Sheenu looked around. 

“Sheenu, you said you have taken penicillin previously.  You had such severe reaction!”

“Previously also I had the same problem after taking the injection sir”, Sheenu answered coolly.

“WHAAAT?  Why did you not tell me?  My god!  It was such a serious reaction.  You are saved.  Never ever take penicillin or any related medicine in future.” Sujay said in a raised voice.

 When Sheenu was about to get up and sit, Sujay asked him to lie down for some more time. Keeping an eye on him Sujay disposed other patients.  Rajaiah was given his yellow injection (B-Complex).  Some pain killers were also given.  He paid the doctor.

“Arey Sheenu, Go home carefully.  If I see your father I will send him.” Rajaiah said as he left the clinic.

After an hour of observation and after checking the general condition, Sheenu was asked to go home. He was given some tablets for fever and cough syrup. By then his father had come.  He was told that Sheenu had serious reaction to penicillin injection and he should never ever take it again in life.

Though Sujay sent the patient home and he returned to his home, he was worried about the patient as he was having abnormally increased pulse rate, the side effect of the anti-reaction injection.  In fact, the next day he was afraid to go the village alone.  So he took his friend along with him for support in case things turned worse.  Fortunately patient had become alright, his fever was less, and was feeling better.  Sujay wrote him some more medicines for further treatment.

Every doctor might face such critical situation many times in their life.  In such conditions if patient could not be saved, doctor feels so depressed as to give up practice for ever.  But once the stress is overcome doctor will again be ready to face challenge with added experience.

After this incident Sujay had made it a practice to ask if patient had any problem after taking any injection or tablet.