Prenatal care generally consists of:
- 1. Monthly visits to the doctors during the first two trimesters (from week 1–28)
- 2. Fortnightly visits to doctor from 28th week to 36th week of pregnancy
- 3. Weekly visits to doctor after 36th week till delivery(delivery at week 38–40)
- 4. Assessment of parental needs and family dynamic.
- 5.Detection of risk factors and its management.
- 6. Care for pregnancies with previous history of complications.
A) Prenatal Examinations :
At the initial antenatal care visit and with the aid of a special booking checklist
the pregnant women become classified into either normal risk or high risk.
Prenatal diagnosis or prenatal screening is testing for diseases or conditions in
a fetus or embryo before it is born. Our obstetricians will monitor mother’s health
and prenatal development during pregnancy through series of regular check-ups.
a) Physical examinations generally consist of
- 1. Collection of (mother’s) medical history
- 2. Checking (mother’s) blood pressure
- 3. (Mother’s) height and weight
- 4.Pelvic examination
- 5. Doppler fetal heart rate monitoring
- 6. (Mother’s) blood and urine tests
- 7. Discussion with caregiver
b) Ultrasound Obstetric ultrasounds :
are most commonly performed during the second trimester at approximately week 20.
Ultrasounds are considered relatively safe and have been used for over 35 years for
monitoring pregnancy. ultrasounds are used to:
- 1. Diagnose pregnancy
- 2. Check for multiple fetuses
- 3. Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition)
- 4. Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists)
- 5. Determine if an intrauterine growth retardation condition exists
- 6. Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones)
- 7. Check the amniotic fluid and umbilical cord for possible problems
- 8. Determine due date (based on measurements and relative developmental progress)
Generally an ultrasound is ordered along a schedule similar to the following:
- 1. 7 weeks — confirm pregnancy, ensure that it’s neither molar or ectopic, determine due date
- 2. 13–14 weeks — evaluate the possibility of Down Syndrome
- 3. 18–20 weeks — see the reasons above
- 4. 34 weeks— evaluate size, verify placental position
B) Investigations First trimester :
- 1. Complete blood count (CBC)
- 2. Blood type
- 3. General antibody screen (indirect Coombs test) for HDN
- 4. Rh D negative antenatal patients should receive RhoGam at 28 weeks to prevent Rh disease.
- 5. Rapid plasma reagin (RPR) to screen for syphilis
- 6. Rubella antibody screen
- 7. Hepatitis B surface antigen
- 8. Gonorrhea and Chlamydia culture
- 9. PPD for tuberculosis
- 10. Pap smear
- 11. Urinalysis and culture
- 12. HIV screen
- 13. Group B Streptococcus screen – will receive IV penicillin or ampicillin if positive.
Genetic screening for downs syndrome (trisomy 21) and trisomy 18 the national standard
in the India is rapidly evolving away from the AFP-Quad screen for downs syndrome- done
typically in the second trimester at 16–18 weeks.
C) Investigations second trimester ::
- 1. MSAFP/quad. screen (four simultaneous blood tests)
(maternal serum alpha-fetoprotein; inhibin; estriol; bHCG or free bHCG) – elevations,
low numbers or odd patterns correlate with neural tube defect risk and increased risks
of trisomy 18 or trisomy 21
- 2. Ultrasound either abdominal or transvaginal to assess cervix, placenta, fluid and baby
- 3. Amniocentesis is the national standard (in what country) for women over 35 or who reach 35 by mid pregnancy or who are at increased risk by family history or prior birth history.
D) Investigations Third trimester :
- 1. Hematocrit (if low, mother will receive iron supplementation)
- 2. Glucose loading test (GLT) – screens for gestational diabetes; if > 140 mg/dL, a glucose tolerance
test (GTT) is administered; a fasting glucose > 105 mg/dL suggests gestational diabetes.
E) Antenatal Record :
On the first visit to us the pregnant woman is asked to carry out the antenatal record,
which constitutes a medical history and physical examination. On subsequent visits,
the gestational age (GA) is rechecked with each visit. The fetus is palpated by the
obstetrician using Leopold maneuver to determine the position of the baby.
Blood pressure should also be monitored, and may be up to 140/90 in normal pregnancies.
High blood pressure indicates hypertension and possibly pre-eclampsia, if severe swelling
(edema) and spilled protein in the urine are also present.
Fetal screening is also used to help assess the viability of the fetus, as well as
congenital problems. Genetic counseling is often offered for families who may be at an
increased risk to have a child with a genetic condition. Amniocentesis, which is usually
performed between 15 and 20 weeks, to check for Down syndrome, other chromosome abnormalities
or other conditions in the fetus, is sometimes offered to women who are at increased risk due to
factors such as older age, previous affected pregnancies or family history.
Even earlier than amniocentesis is performed, the mother may undergo the triple test, nuchal screening,
nasal bone, alpha-fetoprotein screening, Chorionic villus sampling, and also to check for disorders such
as Down Syndrome. Amniocentesis is a prenatal genetic screening of the fetus, which involves inserting a
needle through the mother’s abdominal wall and uterine wall. Amniocentesis is required only when there is
very high risk of having chromosomally abnormal baby as a confirmatory test.
F) Fetal assessments :
Obstetric ultrasonography is routinely used for dating the gestational age of a pregnancy from the
size of the fetus, the most accurate dating being in first trimester before the growth of the fetus
has been significantly influenced by other factors. Ultrasound is also used for detecting congenital
anomalies (or other fetal anomalies) and determining the biophysical profiles (BPP), which are generally
easier to detect in the second trimester when the fetal structures are larger and more developed.
Specialized ultrasound equipment can also evaluate the blood flow velocity in the umbilical cord,
looking to detect a decrease/absence/reversal or diastolic blood flow in the umbilical artery
Other tools used for assessment include:
- 1. Fetal karyotype can be used for the screening of genetic diseases. This can be obtained via amniocentesis or chorionic villus sampling (CVS)
- 2. Fetal hematocrit for the assessment of fetal anemia, Rh isoimmunization, or hydrops can be
determined by percutaneous umbilical blood sampling (PUBS) which is done by placing a needle through
the abdomen into the uterus and taking a portion of the umbilical cord.
- 3. Fetal lung maturity is associated with how much surfactant the fetus is producing.
Reduced production of surfactant indicates decreased lung maturity and is a high risk factor
for infant respiratory distress syndrome. Typically a lecithin:sphingomyelin ratio greater
than 1.5 is associated with increased lung maturity.
- 4. Nonstress test (NST) for fetal heart rate
- 5. Oxytocin challenge test
G) Complications & Emergencies :
The main emergencies include
- 1. Ectopic pregnancy is when an embryo implants in the Fallopian tube or (rarely) on the ovary or inside the peritoneal cavity.
This may cause massive internal bleeding.
- 2. Pre-eclampsia is a disease which is defined by a combination of signs and symptoms that are related to maternal hypertension.
The cause is unknown, and markers are being sought to predict its development from the earliest stages of pregnancy. Some unknown factors
cause vascular damage in the endothelium, causing hypertension. If severe, it progresses to eclampsia, where a convulsions occur, which can
be fatal. Preeclamptic patients with the HELLP syndrome show liver failure and disseminated intravascular coagulation (DIC).
- 3. Placental abruption where the patient can bleed to death if not managed appropriately.
- 4. Fetal distress where the fetus is getting compromised in the uterine environment.
- 5. Shoulder dystocia where one of the fetus’ shoulders becomes stuck during vaginal birth, especially in macrosomic babies of diabetic mother.
- 6. Obstetrical hemorrhage may be due to a number of factors such as placenta previa, uterine rupture or tears, uterine atony, retained
placenta or placental fragments, or bleeding disorders.
- 7. Puerperal sepsis is a progressed infection of the uterus during or after labor.
H) Intercurrent diseases
In addition to complications of pregnancy that can arise, a pregnant woman may have intercurrent
diseases, that is, other diseases or conditions (not directly caused by the pregnancy) that may become
worse or be a potential risk to the pregnancy.
- 1. Diabetes mellitus and pregnancy deals with the interactions of diabetes mellitus
(not restricted to gestational diabetes) and pregnancy. Risks for the child include miscarriage,
growth restriction, growth acceleration, fetal obesity (macrosomia), polyhydramnios and birth defects
- 2. Systemic lupus erythematosus and pregnancy confers an increased rate of fetal death in utero and spontaneous abortion (miscarriage), as well as of neonatal lupus
- 3. Thyroid disease in pregnancy can, if uncorrected, cause adverse effects on fetal and maternal
well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery
to affect neurointellectual development in the early life of the child. Demand for thyroid hormones is
increased during pregnancy which may cause a previously unnoticed thyroid disorder to worsen.
- 4. Hypercoagulability in pregnancy is the propensity of pregnant women to develop thrombosis
(blood clots). Pregnancy itself is a factor of hypercoagulability (pregnancy-induced hypercoagulability),
as a physiologically adaptive mechanism to prevent post partum bleeding. However, when combined with an
additional underlying hypercoagulable states, the risk of thrombosis or embolism may become substantial
I) Childbirth :
Induction is a method of artificially or prematurely stimulating labour in a woman.
Reasons to induce can include pre-eclampsia, placental malfunction, intrauterine growth
retardation, and other various general medical conditions, such as renal disease. Induction
may occur any time after 34 weeks of gestation if the risk to the fetus or mother is greater
than the risk of delivering a premature fetus regardless of lung maturity.
Induction may be achieved via several methods
- 1. Pessary of Prostin cream, prostaglandin E2
- 2. Intravaginal or oral administration of misoprostol
- 3. Cervical insertion of a 30-mL Foley catheter
- 4. Rupturing the amniotic membranes
- 5. Intravenous infusion of synthetic oxytocin (Pitocin or Syntocinon)
J) Labour :
During labor itself, the obstetrician may be called on to do a number of tasks. These tasks can include:
- 1. Monitor the progress of labor, by reviewing the nursing chart, performing vaginal examination,
and assessing the trace produced by a fetal monitoring device (the cardiotocograph)
- 2. Accelerate the progress of labor by infusion of the hormone oxytocin
- 3. Provide pain relief, either by nitrous oxide, opiates, or by epidural anesthesia done by anaesthestists, an anesthesiologist, or a nurse anesthetist.
- 4. Surgically assisting labor, by forceps or the Ventouse (a suction cap applied to the fetus’ head)
- 5. Caesarean section, if there is an associated risk with vaginal delivery, as such fetal or maternal compromise supported by evidence and literature
K) Post natal Care :
Postnatal care is care provided to the mother following parturition. A woman in the city like Mumbai who
is delivering in a hospital may leave the hospital as soon as she is medically stable and chooses to leave,
which can be as early as a few hours postpartum, though the average for spontaneous vaginal delivery
(SVD) is 1–2 days, and the average caesarean section postnatal stay is 3–4 days.
During this time the mother is monitored for bleeding, bowel and bladder function, and baby care.
The infant‘s health is also monitored.
Certain things must be kept in mind as the physician proceeds with the post-natal care
- 1. General Condition of the patient.
- 2. Check for Vital Signs (Pulse, Blood Pressure, Temperature, Respiratory Rate, (Pain) at times)
- 3. Palor, Edema, Dehydration, Lochia (colour, amount, odour)
- 4. Fundus (height following parturition, and the feel of the fundus) (Per Abdominal Examination)
- 5. If an Episiotomy or a C-Section was performed, check for the dressing. Intact, pus,
- 6. Bladder (keep the patient catheterized for 12 hours following local anaesthesia and 24–48 hours after general anaesthesia) (check for bladder function)
- 7. Bowel Movements
- 8. Follow up with the neonate to check if they are healthy
MEDICAL TERMINATION OF PREGNANCY
Abortion is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior
to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely
induced. The term abortion most commonly refers to the induced abortion of a human pregnancy.
The Indian abortion laws fall under the Medical Termination of Pregnancy (MTP) Act, which was enacted by the Indian
Parliament in the year 1971. The MTP Act came into effect from April 1, 1972 and was once amended in 1975.
The Medical Termination of Pregnancy (MTP) Act of India clearly states the conditions under which a pregnancy can be ended
or aborted, the persons who are qualified to conduct the abortion and the place of implementation. Some of these qualifications
are as follows
- 1. Women whose physical and/or mental health were endangered by the pregnancy
- 2. Women facing the birth of a potentially handicapped or malformed child
- 3. Rape
- 4. Pregnancies in unmarried girls under the age of eighteen with the consent of a guardian
- 5. Pregnancies in “lunatics” with the consent of a guardian
- 6. Pregnancies that are a result of failure in sterilisation
- The length of the pregnancy must not exceed twenty weeks in order to qualify for an abortion.
a) Medical – Medical abortions are those induced by abortifacient pharmaceuticals. The most common early first-trimester
medical abortion regimens use methotrexate in combination with a prostaglandin analog up to 7 weeks gestation.
Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than
methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone.
If medical abortion fails, surgical abortion must be used to complete the procedure.
b) Surgical – Up to 12 weeks’ gestation, suction-aspiration or vacuum aspiration are the most common surgical methods
of induced abortion. These techniques differ in the mechanism used to apply suction, in how early in pregnancy they can be
used, and in whether cervical dilation is necessary. Dilation and curettage (D&C) the second most common method of surgical
abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine
lining for possible malignancy, investigation of abnormal bleeding, and abortion. In the third trimester of pregnancy,
abortion may be performed by induction of labor, or by hysterotomy.
B) Contraindications due to Medical Reasons
- 1. Smoking > 35 years
- 2. Anemia – hemoglobin < 8 gm %
- 3. Suspected /confirmed ectopic pregnancy / undiagnosed adnexal mass
- 4. Coagulopathy or women on anticoagulant therapy
- 5. Chronic adrenal failure or current use of systemic corticosteroids
- 6. Uncontrolled hypertension with bp >160/100mmhg
- 7. Cardio-vascular diseases such as angina, valvular disease, arrhythmia
- 8. Severe renal, liver or respiratory diseases
- 9. Glaucoma
- 10. Uncontrolled seizure disorde