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.

Pregnancy - General Care

We all know that pregnancy is a physiological condition needing special care.  Though a natural phenomenon, it is a special condition when a woman needs professional and tender loving care from the medical professional as well as family members.  A woman becoming pregnant for the first time will be more anxious and will have many doubts about what to eat and what activities she can carry on.

Diet:  The calorie requirement of average Indian woman doing moderate work is 2200kcal/day.  If the activity is less less calories are required.  Average Indian diet has more carbohydrates contributing almost 70-80% kcal.  The rest obtained from fats and proteins.  But it is best to have 50-60%kcal from carbohydrates, 25-30%kcal from proteins and the rest from fats.  All the vitamins, minerals are obtained from various food items including fruits and vegetables. 

In pregnancy as the woman nurtures another life in her body she has to take more food. The burden of pregnancy requires woman to increase calorie intake by 15-20% during the course of pregnancy and another 5%-10% in the lactational period.  This is about extra 300kcal in pregnancy and 500kcal in first 6months of feeding and 400kcal in the next 6 months of feeding. 

As pregnancy is a body building process protein requirement is increased and it will be good to increase intake of more proteinecious foods like pulses, eggs, meat, fish and milk.

Gravida need not eat double of what she eats.  If she increases to take cereals and fats marginally and doubles the protein supplementing foods and fruits and vegetables she will meet all the needs of pregnancy nutrition.   For an average Indian diet, if the gravida adds two glasses of milk (300ml), an egg, fistful (20gm) of pulses soaked and sprouted, and any fruit like banana, guava or any seasonal fruits one or two (100gm) will provide almost all the extra nutrients and calories required for healthy fetal development.

High calorie non fibre foods and drinks are avoided.  Instead of having just two meals, food intake should be every two three hours in the day.  What ever food is taken it is better divided into appropriate portions and taken as breakfast, lunch, supper and two snacks.  Snacks can be fruits and sprouts along with milk taken early in the morning, between breakfast and lunch and lunch and supper. 

Physical Activity:  A healthy gravida can carry all the physical activities she is accustomed to previously.  Routine domestic chores, and other activities like walking and swimming can be carried out as long as she is comfortable. Yoga, and aerobics can be done only under the expert guidance.  Two hours rest in the afternoons and eight hours rest at night will keep the woman healthy.

 Employment:  Woman doing sedentary jobs can continue to do.  Employment where a gravida has a possibility of getting exposed to radiation or chemical fumes or severe physical exertion like lifting heavy weights should be avoided.  These activities can adversely affect fetal development or continuation of pregnancy till term. 

Travel:  Long distance journeys, strenuous traveling, traveling in early and late pregnancy is best avoided.  This is to avoid the woman being away from the doctor if any problem arises, particularly in late pregnancy.  If the gravida has any problem of bleeding or abdominal pain or cramps anytime, journeys are avoided other than to visit the doctor.

Sexual Activity:  A healthy gravida with a normal pregnancy in a healthy relationship can have sexual activity as long as it does not hurt her.  Over indulgence is avoided.  Complete abstinence is not a must.  If there is possibility of genital infections sexual activity must be completely avoided.  Also when gravida has history of previous abortions, or premature deliver or has bleeding in the present pregnancy or cramps in the abdomen or due to certain pregnancy conditions when the obstetrician advises abstinence is must.  It is best to restrict sexual activity in early pregnancy for fear of abortion and in late pregnancy, premature delivery.

 Addictions: Everybody is aware of the adverse effects of smoking and excessive alcohol intake and drug addictions.  All these, smoking, alcohol and ‘drugs’ have harmful effects on the fetus and compromise even maternal health and increase certain complications in pregnancy.  Hence smoking, alcohol and drugs are a strict “NO’ in pregnancy.

Healthy diet, appropriate physical activity and rest will result in healthy pregnancy resulting in the birth of healthy baby.

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. 

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