Models

Nature is always beautiful even in its wilderness.  When it comes to human beings beauty varies depending on the eyes that see.  A person who is classified as world’s most beautiful woman or man may not be considered so by everyone on earth or even in the place to which that person belongs.  Woman is considered as object of beauty by man and man had set certain criteria for woman to look beautiful.  The beauty of woman is judged basically by physical appearance.  In show biz, if a woman has to survive she should modify her body as per the criteria set by man.  The obvious criteria are the body weight and height.  Tall and thin woman are considered beautiful.

In fashion industry, models are generally slim and tall.  When a model does the ‘cat walk’ they put a typical stoic expression on face and eyes looking vacant.  They are vigorously groomed to maintain low body weight to survive in the industry.  Young girls, particularly those in teenage, with hormones having their blast on the body, want to ape models in appearance to look attractive.  To look thin many girls avoid eating healthy and suffer eating disorders, anorexia or bulimia.  A model, Isabelle Cano, a French fashion model died of anorexia in 2007 after a photo shoot to campaign against becoming extremely thin.  After her death a law enacted in France for regular weight checks for models and anybody actively involved in weight reduction of model's body mass index to less than 18 is fined or even be jailed. 

 France, Italy, Spain and Israel have adopted laws against too thin models on catwalks or in advertising campaign in 2013.

The minimal body mass index is 18.  The range is 18 -25.  Any body mass index out of this range requires attention and appropriate measures to maintain ideal body weight

Body mass index is calculated as weight in kilograms divided by height in square metres

                             Weight in kilograms

                             -------------------------

                            Height in square metres

Ex: 60/ (1.65x1.65) = 22 BMI.

A simple way to know one’s ideal body weight is to subtract hundred from height measured in centimeters.

165 (Ht) – 100 = 65 Kg, Ideal weight.

65/ (1.65x1.65) = 23.87 BMI.

Health is wealth.  Proper diet and exercise help in maintaining ideal body weight and good health.

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.

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.

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. 

Fertility

Sometimes the biology of woman makes her vulnerable to mean criticism.  This is particularly problematic if she conceives within the first month of her marital life.  If the husband and in-laws understand she will have a peaceful life.  Otherwise she will be subjected to mental trauma. 

Once, a newly married couple had come to me.  Parents-in-law also accompanied.  Young bride was shy and sat silently.  Mother-in-law told me that the girl was supposed to get her periods that week but did not get it.  I asked for pregnancy test and pregnancy was confirmed.  Except the girl there was disbelief in all others’ face.  The boy said he is married just three weeks ago and doesn’t want to have children so soon.  He expressed his doubt that how can a pregnancy occur so early and what could be the duration of pregnancy.  I understood that he is suspecting the girl’s fidelity.  He opted for a scan.  The scan was showing early gestational sac, with a fetal node – suggestive of early pregnancy of 5-6 weeks.  Now all he wanted to know if that marriage had taken place only three weeks ago how can she be more than 5 weeks pregnant.  That is a genuine doubt.

In obstetrics we count pregnancy duration – gestational age, in weeks.  This is counted from the first day of bleeding of menstrual cycle (MC).  The onset of bleeding in a MC is clearing of  the old endometrium (inner most layer of uterus which lodges embryo, nourishes in early stages and develop attachment to placenta to sustain fetus until delivery).  New endometrium starts developing along with ovum in the ovaries.  The changes in ovum that is to be released and fertilized, and endometrium so as to provide nutrition in case of successful fertilization and implantation of embryo that happens in the 3^rd week of MC.  The normal MC is 28 days cycle.  It could vary a few days – 26 to 30 days.  In a 28 day MC ovum is released on 14^th day.  If the cycle duration is more it may be delayed, in a shorter cycle it may be early.  In general, in normal MC the fertile period – chance of conception is from 12^th to 16^th day.  The first two weeks of preparatory period is also added when pregnancy dating is done.  So getting married in the 3^rd week of MC and being diagnosed to have 5weeks pregnancy a week after missing periods is perfectly normal.  There is nothing to suspect any mischief by the girl.  Though obstetrician explains the newly weds and their family the biology of conception and dating, few still doubt.   Illogical doubting spoils future togetherness.  It is good to have scientific understanding of ovulation, fertility and dating of pregnancy which will help in future family planning.

The fertility period in a woman with regular MC of 28 to 30 days is 12^th to 18^th day of MC.  First day of bleeding is considered as first day of MC.  Contraceptive methods are used to prevent either release of ovulation (OC pills) or prevent contact of sperm with ovum (barrier methods, abstinence), or prevent implantation (Intra uterine devices, emergency pill).  This awareness of fertility period in the woman helps to prevent unwanted pregnancy and improve health of woman.

Contraception

We all know that prevention is better than cure.  But in practice this principle is followed by few, particularly when it comes to avoiding unwanted pregnancy.  Except the highly educated and living in metros very few couple opt for contraception in the early days of their married life.  The first pregnancy if occurs within a month or two, there will be unending discussions whether to continue pregnancy or undergo abortion.  The girl simply has to oblige wishes of husband/in-law’s family.  This will be quite unpleasant in the early days of marriage. 

Even after abortion and delivery very few couple chooses any contraceptive method.  This is due to lack of awareness and unnecessary apprehensions.

There are many simple methods of avoiding pregnancy – using contraception.  Depending on the couple’s choice, the duration of contraception requirement gynecologists will suggest appropriate method.  As of now except the male condoms all methods are for use by women.  The only contraceptive that can be used by male is ‘condom’. 

The various methods of contraception are -

Natural methods:  The fertile period of woman, strictly speaking, is only 5 days in a menstrual cycle.  In a 28day menstrual cycle ovum is released on the 14^th day or otherwise it can also be said to occur 14 days before the onset of bleeding – first day of periods.  The life of ovum is 48 hours and that of sperm is 72 hours.  So the possibility of conception is from 12^th to 16^th day is high.  A woman having 30days+/-2days cycle should abstain from sexual activity from 12^th to 18^th day of the menstrual cycle (first day of bleeding is considered as first day of menstrual cycle).  This one week is unsafe and any couple wants to avoid pregnancy should either avoid sexual activity (abstinence) or male should withdraw and allow the ejaculation outside the vagina (coitus interruptus).  The failure rate in this method is high.

Barrier method:  This is the method which prevents live sperm meeting the ovum.  Condoms come in this category.  Male condoms are most widely used.  Condoms not only prevent pregnancy but also prevent sexually transmitted diseases.  Male condoms are easily available, can be carried easily, inexpensive and simple to use by males and when properly used the failure rate is 2-3/100 women years (100x12).  Failure could be due to improper usage or tears in the condom. 

Female condoms are costly and bulky to carry.  Failure rate is 5/100 women years.

The chemical barrier is the use of spermicidal jellies or douches.  The common spermicidal agent nonoxynol-9 is available as ‘Today’, to be inserted in the vagina before the act.  This can prevent pregnancy but not infections.

Hormonal methods:  Hormonal contraceptives are the best means of avoiding pregnancy as their effectiveness is 100% when used correctly.  Hormonal pills or OC pills are available in different formulations using estrogen and progesterone.  When both the hormones are used, it is combined pill.  Combined pill can be available as single or biphasic and triphasic depending on amount of hormones used to mimic normal menstrual cyclic changes in the hormones.  Usually fixed dose pills are used.  Combined pills are generally available in pack of 20 or 21.  These are started on first or second day of periods and not later than 5^th day or as advised by manufacturer.  Once started, pills should be taken regularly at the same time – preferably bed time, till the pack is over.  After stopping the pills bleeding starts within a week.  The pills can be used as long the contraceptive protection is needed. 

There are also pills with progesterone only.  These are in particular useful in breast feeding woman. 

The pill which is presently misused by the young generation is post-coital pill.  This is also called as morning after pill and used as emergency contraception. The pills contain large doses of hormones and effective when used within 72 hours of coitus.  But this is only an emergency pill, and the large dose of hormones in these pills may cause more side effects.

Injectable contraceptives that are estrogen free are also available.  These injections can be taken once in 60-90 days depending on the type of injection.

The important side effect of hormones is thrombo-embolism affecting cardiovascular system.  But the low dose of estrogen in the OC pills, estrogen free pills and injections has reduced this troublesome side effect.  The use of injections is supposed to cause some amount of demineralization of bones which reverts to normal once the usage is stopped.  The other common side effects like spotting can be overcome by using appropriate dose pill. 

There are definitely some beneficial effects of OC pills.  The cycles become regular, pain during periods lessens, bleeding is reduced and helps in reducing anemia.  Also studies have shown that pill use may give protection against benign breast disorders and ovarian cancer. 

Non-hormonal pills:  Centchroman 30mg per day twice weekly for 3 months followed by once weekly is a good non-hormonal contraceptive pill.  The only side effect is delayed periods.  This is somehow not easily availble in the medical stores.

Intra-uterine devices (IUD):  These are the small devices placed in the uterus to prevent pregnancy.  These are made of polyethylene or other polymers.  They are usually ‘T’ shaped. These can be medicated and non- medicated.  The commonly used devices have thin copper wires wound around the stem of the device.  Copper has strong anti-fertility effect.  The medicated device is with progesterone in time release form – Progestasert and Mirena. 

The common side effects with IUD is occasional spotting, increased menstrual flow with cramps.  This will subside within a month or two.  There is chance of infection in women with multiple partners.  The failure rate is 3% in the first year. The progesterone medicated IUD, is more beneficial as it protects women against excessive bleeding and reduces anemia.  The advantage of IUD is once inserted and tolerated it can be left in situ depending on prescribed duration of effectiveness(3-5 years) or removed earlier when woman decides to conceive.

In general use of contraception protects women against unwanted pregnancy and abortion with it attendant complications.  Abortion subjects women to more physical, mental, social trauma and financial liabilities.  Any woman who wants to use contraception other than barrier or natural methods should consult a gynecologist and use appropriate method as per her health and requirements. 

There are other forms of contraceptives like diaphragms, vaginal rings which are not commonly used and hormonal implants that need implanting tiny rods with hormones subdermally and removed after the scheduled period or as required.

This is simplified information about contraceptives.  This is to encourage women to protect them from unwanted pregnancy and abortion with its attendant complications.  Abortion contributes to 13% of maternal mortality.  Most of it occurs in the developing world.  Contraception will prevent 218 millions of unwanted pregnancies, averts 138 millions abortions with its morbidity and mortality in a year.

All the contraceptive methods have their effect only when they are used.  They do not affect future prospects of pregnancy or have effect on the progeny. 

For a healthy, happy family life the couple should adopt convenient contraceptive method early in the marital life and later for spacing childbirth.  The permanent method of contraception is ‘tubectomy’ in women and ‘vasectomy’ in men.  

New Life

The other day I had one young patient, just 20yrs and married a month ago.  She had come for some general complaint.  I asked her whether she would like to have children early or want to postpone for a certain period.  She said she did not think about it.  She wants to ask her husband and elders.  But then, she asked me the right time to have children.  “When you couple decide to have it”, I said.

After that girl went out I was just thinking about the right time to plan conception – child birth for a couple.  Each may have a different time, for the reasons best known to that couple.  A couple should not try to beget child just because someone in their peer group have given birth to a child or parents and relatives on either side are frequently asking for ‘good news’ or for some such reason compelled to prove their fertility.  Child birth should be happy occasion, and the couple should welcome its arrival in blissful joy of companionship.

To bring a new life into this world the physical and financial health of the couple is of prime importance.  As for the physical health, more importance is attached to the health of the woman – would be mother.  A healthy mother begets healthy child.  The fertility of woman is at its peak between 20 and 30 years age.  This is also the period when the incidence of pregnancy complications is low.  After the age of 30 years the fertility decreases slowly, and after 35 years the incidence of ‘Down Syndrome’ increases gradually.  The possibility of health problems arising after 35 years age will also contribute to increase in congenital anomalies in the fetus and increased incidence of complications in pregnancy.  But in the present day with improved medical care women are conceiving even at the age of 60, delivering healthy grand children (surrogacy).  

Even in young age (20-30 years) some women may  have health problems.  Prior to planning pregnancy, it will be good to consult an Obstetrician and have a general health check-up and basic investigation like hemoglobin percent, blood grouping and Rh typing.  Anemia is most prevalent; almost 50% of women are anemic.  This should be corrected.  If there are any other health problems like heart disease, epilepsy, hypertension, diabetes mellitus, they should get advice from the physician who may advise change in medication.  In case of infections like tuberculosis or any other infection it is better to wait until the due course of treatment is completed.  Hypothyroidism is another endocrinal disorder which is common and sub clinical hypothyroidism can only be known by blood examination only.  Appropriate medication should be started.  Taking these precautions will help in healthy pregnancy and child birth.

With increasing consumerism and commercialisation of all fields it is essential to consider financial aspects of bringing in a child into this world.  People of every status have their own level of care facilities.  As per the status of the couple the finances, not only of the child birth, but the upbringing of the child also should be considered.  The coming generation is very demanding.  From the day of conception till the child evolves into an adult and carries on its life needs parental care, guidance and financial assistance.  Keeping the rising costs of education and all logistics essential to carry forward the generation in view, the couple should also plan their finances and support systems.

Support systems are particularly essential in bringing up the child.  Money doesn’t provide love and emotional support to the child.  It is the parental care that makes all the difference in the life of a child.  Quality time devoted to the child makes it strong mentally and goes a long way in social and spiritual health of the child. 

Procreation is a natural phenomenon.  Without any planning or thinking a new life can start on this earth naturally and live to its destiny.  But in these days of striving for brands and designs, it is appropriate to plan and prepare oneself for the task of bringing in new generation that can make this earth heaven.