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”.

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. 

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.

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.