Pregnancy Care

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Pregnancy is very caring period when mother want’s total care. It is important that you go for expert pregnancy consulting during this phase. 

Doctor will provide complete check-up, usually with a physical exam and blood and urine tests to make sure you’re healthy. 

• Preconceptional Counseling and care
• Antenatal Check up 
• NST
• High Risk Pregnancy 
• Normal delivery 
• Painless Delivery 
• LSCS
• Postnatal Care
• Ectopic pregnancy

• Preconceptional care is when couple is seen and counselled about pregnancy well before actual pregnancy.
• Objective of preconceptional care is to ensure that a woman enters in pregnancy with optimal health which would be safe for both to herself and baby.
• Although only a small percentage of women take the advantage of preconceptional care due to lack of awareness and also most of the  pregnancies are unplanned.

Antenatal care is regular and periodic supervision of a woman during pregnancy. 

The care should start from the beginning of pregnancy and should end at delivery.

Antenatal care includes careful history, examination, and advice given to pregnant women.

Aims- The aims of antenatal care are

1) To detect high-risk pregnancy

2) To detect and treat any complications at the earliest.

3) To educate the mother about the pregnancy

4) To provide necessary supplements

5) To discuss the place, time, and mode of delivery.

Objectives- To ensure a normal pregnancy with the delivery of a healthy baby from a healthy mother.

Generally, antenatal check-up is done at intervals of 

-4 weeks up to 28 weeks

-2 weeks up to 36 weeks

- weekly till delivery

But it should be more flexible depending upon the need of individual woman.

Normal labor is the physiological process of childbirth by regular uterine contractions leading to dilatation and effacement of the cervix leading to delivery of the fetus and placenta.

Normal delivery is a reflexive and spontaneous action of bearing down to expel the fetus and placenta.

In Normal delivery, baby is born head first, through the vagina, at term (after 37 weeks of pregnancy). 

Unless there is any indication to intervene all women with low-risk pregnancies should be encouraged to normal labour and delivery.

Although some medical interventions may be needed to support or help delivery as rupture of membranes, labour augmentation with medications (e.g. oxytocin), or use of medications or epidural analgesia for pain relief and surgical intervention in the form of episiotomy specially during first delivery.

But if labour process is not going normally, interventions like laour augmentation, forceps or vaccum delivery or Caesarean Section are needed to assist the process of delivery.

What is painless labour- 

First time mother-to-be offen fear natural birth. Painless labour or delivery is a technique where a specific concentration of drug is used through epidural route. Although drug reduces the pain of labour it maintains the ability to push the baby out through birth canal.

How is epidural analgesia administered-

An anaesthetist administers epidural catheter in lower back by inserting a thin tube into lower part of spinal cord. Catheter is taped into place so that the anasthesia can be administered during labour.

Epidura analgesia is administered in active labour and work by reducing labour pain.

Advantages-

-Reduces labour pain, relaxes and prevent exhaution and irritation experient by most women during labour.

- It helps in labour by relaxing the pelvis and vaginal muscles.

- Helps to lower blood pressure specially in women with pregnancy induced hypertension.

Risks- 

- Hypotension ( low blood pressure)

- Pain at insertion site

- Headache

- In very few patients difficulty in passing urine and those women may need catheterization.

Couple of other options for painless delivery are there but painless delivery using an epidural analgesia has helped many women for pain relief during natural birth and should be offered to all women who are anxious about labour pain and are good candidate for normal delivery.

Caesarean section is a way of delivering a baby by surgery. 

It is an operative procedure whereby baby is delivered through an incision on abdominal and uterine wall after 28 completed weeks of pregnancy.

Incidence- Survey done between June 2019-April 2021, released by health ministry showed that National Caesarean Section rate is 21.5%.

World Health Organization term ideal Caesarean Section rate between 10-15%.

Reasons behind increased Caesarean Section rates in India are

- First pregnancy at an age of 30 years or more.

- Repeat Caesarean Delivery in case of previous Caesarean birth.

 - Identification of risk factors related to mother and baby as Pregnancy Induced Hypertension,  Gestational Diabetes etc and any growth specially in lower part leading to mechanical obstruction.

 - Decline in difficult vaginal delivery

Time of Operation-

A) Elective or Planned Surgery- Planned Caesarean Section is done in pregnancy with abnormal position of baby, problems of growth of baby, mothers having diabetes and/or high blood pressure, any growth in pelvis and history of previous surgery where normal delivery is not suitable.

Maturity of baby and risk of continuation of pregnancy on health of mother and baby are two important factors for deciding the time of delivery.

B) Emergency Surgery- Most common reason is fetal distress and nonprogress of labour.

A) Lower Segment Caesarean Section- In this type baby is born through a cut on lower segment of uterus. This is the only method used in present day practice unless it is not safe to do. In those circumstances classical Caesarean Section is done.

B) Classical Caesarean Section- Baby is delivered by making a cut in upper part of uterus in cases where approach to lower part of uterus is difficult due to previous surgery or severe degree of contracted pelvis or big fibroid in lower segment ( although removal of fibroid followed by lower segment Caesarean Section is equally good in expert hand)

Complications of Caesarean Section- 

Complications may be early or late complications. 

Early complications are extension of surgical scar, bladder or ureter injuries, injury to gut, excessive bleeding and shock, infection of wound. 

Late complications are in chronic pelvic pain, backache, menstruation abnormalities, incisional hernia and risk of scar rupture in future pregnancy. 

High risk pregnancy is pregnancy complicated by factor or factors that adversely affect mother and baby or both.

Although all pregnancy and deliveries are potentially at risk, there are certain categories of pregnancies where mother and baby is in a state of increased jeopardy.

About 20-30% of pregnancies are high risk pregnancies.

This group must be identified and given extra care as this small group is responsible for 70-80% of complications of baby, 50% pregnancy complications of mother and 60% of all primary Caesarean Section.

Screening of High Risk Pregnancy-

All pregnant women should be thoughly assessed at first visit for high risk pregnancy. 

High risk pregnancies are

- Pregnancy below the age of 17 years & above the age of 35 years.

- First pregnancy after 30 years of age.

- Two or more previous abortions- risk of further abortion or preterm delivery.

- Previous history of delivery of dead baby or death of baby after birth.

- Previous history of birth of baby with birth defects.

- Previous preterm labour or birth of low birth weight baby.

- History of birth of four or more babies.

- Anaemia ( low blood levels)

- High Blood pressure- both before pregnancy or pregnancy induced. 

- Mother with negative blood group and father of positive blood group.

- Disease of heart, lung and liver.

- Thyroid problems

- History of fits and psychological illnesses

- History of heavy bleeding after delivery of baby or retain placenta- these complications has particular tendency to recur. 

- Previous history of operations like Caesarean Section, Hysterotomy, Myomectomy or repair of Complete Perineal Tear, Vesicovaginal fistula and Stress incontinence.

Number of antenatal visits and management protocol is specific for each pregnancy depending upon the factor or factors responsible for categorising that specific pregnancy as high risk pregnancy.

Postpartum means time after childbirth.

Postpartum care refers to issues related to mother and baby from birth upto six weeks.

First 24 hours after delivery of baby known as immediate postpartum period when complications of delivery and anaesthesia may occur.

First week post delivery is known as early postpartum period. Wound infection and breast issues are main concern.

Upto 6 weeks post delivery is remote postpartum period when the pregnancy changes of body are returns to normal non pregnant state.

Aims of postpartum care-

- To restore the health status of mother

 - To prevent infections

 - Breast care

 - To motivate couple for contraception.

Postpartum care includes

-Rest and proper sleep- Although early ambulation provide a sense of well-being and has its own medical benefits, it doesn't mean an immediate return to normal activity or work. Lethargy and fatigue are common after delivery therefore rest is essential.

-Diet-  Regular diet should be recommended at earliest possible. Protein rich foods, fruits, vegetables, milk products and high quantity of fluids are recommended specially for nursing mother. Mother who is breast feeding her child needs  approx 500 Kcal per day, 1000 mg of Calcium per day and 15 grams of protein per day over and above her normal requirements.

-Care of Bowel, Bladder and Perineum- Regular emptying of bladder, regular gut movement and care of episiotomy wound of perineum is essential part of postpartum care.

-Emotional Reactions-  First response of mother following birth of a normal baby is usually one of extreme relief and happiness. It is usually followed by touching, holding,and grooming of baby. Although few mothers may react differently. These reactions may range from relatively mild and transient maternity blues to more severe depression and rare postpartum psychosis. Postpartum or maternity blue occur in upto 70% of women after delivery and appear to be a normal psychological response or adjustment. It menifests usually by tearfullness, anxiety, irritation, restlessness, depression, confusion, headache insomnia and even negative feelings towards baby. It is usually transient, occurs within the first few days after delivery and ceases by postpartum day 10. Family and spouse should be best support after delivery by being good to mother and by deviding the responsibility of new born baby.

- Breast care- breast care is an essential part of postpartum care. First two day after delivery of baby yellowish secretion from nipples is known as colostrum. Milk secretion actually starts from 3rd or 4th day after delivery. Breasts become engorged, tense, painful and warm. Transient fever is also common at this stage. Mother usually gets a sense of rise of pressure in breast by milk at the beginning of sucking by baby. Early and exclusive breastfeeding and feeding in correct posture prevent most of the problems related to breast issues.

Pregnancy begins with a fertilized egg which normally get attached to the inner lining of uterus. If the fertilized egg get attached outside the uterus it is known as ectopic pregnancy.

Ectopic pregnancy can't proceed normally. Fertilized egg can't survive outside the uterus. If left to grow it may damage nearby organs and leads to life threatening haemorrhage.

Sites of Ectopic Pregnancy-

1) Tubal Pregnancy- Tube carries eggs from ovaries to uterus. Fertilization of eggs occur in tubes. So tubes are most common site of ectopic pregnancy. Other sites are

2) Ovarian pregnancy

3) Abdominal pregnancy

4) Cervical pregnancy

Symptoms of Ectopic Pregnancy- early ectopic pregnancy may be asymptomatic. Although few women may have usual early signs of pregnancy i.e. missed period, nausea, breast tenderness with positive pregnancy test.

As the fertilized egg grows at abnormal site for pregnancy, signs and symptoms become more noticeable.

Warning signs of ectopic pregnancy are

- Pelvic pain

-Vaginal bleeding

With internal bleeding and blood getting collected inside abdomen woman will develop 

- shoulder pain

- severe abdominal pain

- fainting attack 

- shock

These symptoms are indicative of internal bleeding and needs emergency intervention to save the life of woman.

Without treatment ectopic pregnancy usually ends with life threatening bleeding.

Risk Factors for Ectopic Pregnancy- Various conditions predisposes a woman for ectopic pregnancy. these are

1) Previous ectopic pregnancy

2) Infection and inflammation- Sexually transmitted diseases such as Chlamydia and Gonorrhoea leads to infection and inflammation of tubes and nearby orgens. 

3) Fertility treatment

4) Tubal Surgery

5) Pregnancy with IUCD in place

6) Pregnancy after tubal ligation failure

7) Smoking 

Diagnosis of Ectopic Pregnancy- Clinical diagnosis is based on typical presentation of signs and symptoms as pelvic pain and vaginal bleeding with lower abdominal tenderness.

Positive pregnancy test and Sonography confirmation of pregnancy outside the uterus with or without presence of blood confirm diagnosis.

Treatment of Ectopic Pregnancy- 

Early ectopic pregnancy without internal bleeding is most often treated with a medicine called Methotrexate.

Surgery is done in cases with ruptured ectopic pregnancy with bleeding or in cases of chronic ectopic pregnancy. Surgery is done by either laproscopy or laprotomy( open surgery).