Obstretics

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period.

 

Pregnancy

Pregnancy is the term used to describe the period in which a fetus develops inside a woman’s womb or uterus.

Pregnancy usually lasts about 40 weeks, or just over 9 months, as measured from the last menstrual period to delivery. Health care providers refer to three segments of pregnancy, called trimesters. The major events in each trimester are described below.

 

First Trimester (Week 1 to Week 12)
The events that lead to pregnancy begin with conception, in which a sperm penetrates an egg. The fertilized egg (called a zygote) then travels through the woman’s fallopian tube to the uterus, where it implants itself in the uterine wall. The zygote is made up of a cluster of cells that later form the fetus and the placenta. The placenta connects the mother to the fetus and provides nutrients and oxygen to the fetus.2

Second Trimester (Week 13 to Week 28)

• Between 18 and 20 weeks, the typical timing for ultrasound to look for birth defects, you can often find out the sex of your baby.
• At 20 weeks, a woman may begin to feel movement.
• At 24 weeks, footprints and fingerprints have formed and the fetus sleeps and wakes regularly.
• According to research from the NICHD Neonatal Research Network, the survival rate for babies born at 28 weeks was 92%, although those born at this time will likely still experience serious health complications, including respiratory and neurologic problems.

Third Trimester (Week 29 to Week 40)

• At 32 weeks, the bones are soft and yet almost fully formed, and the eyes can open and close.
• Infants born before 37 weeks are considered preterm. These children are at increased risk for problems such as developmental delays, vision and hearing problems, and cerebral palsy.Infants born between 34 and 36 weeks of pregnancy are considered to be “late preterm.”
• Infants born in the 37th and 38th weeks of pregnancy—previously considered term—are now considered “early term.” These infants face more health risks than infants who are born at 39 weeks or later, which is now considered full term.
• Infants born at 39 or 40 weeks of pregnancy are considered full term. Full-term infants have better health outcomes than do infants born earlier or, in some cases, later than this period. Therefore, if there is no medical reason to deliver earlier, it is best to deliver at or after 39 weeks to give the infant’s lungs, brain, and liver time to fully develop.
• Infants born at 41 weeks through 41 weeks and 6 days are considered late term.
• Infants who are born at 42 weeks and beyond are considered post term.

Diet in pregnancy:

During pregnancy, the goal is to be eating nutritious foods most of the time,emphasizing the following five food groups: fruits, vegetables, lean protein, whole grains and dairy products.

Fruit and vegetables

Eat plenty of fruit and vegetables because these provide vitamins and minerals, as well as fibre, which helps digestion and prevents constipation.Cook vegetables lightly in a little water, or eat them raw but well washed, to get the benefit of the nutrients they contain.

Protein

Foods containing protein help the baby grow. Sources of protein include beans, legumes/beans, nuts., eggs,meat (but avoid liver) and fish.
Whole grains. These grains are either present in their whole form or ground into a flour while retaining all parts of the seed (bran, germ and endosperm).Examples of whole grains include Barley,Brown rice,Buckwheat,Bulgur (cracked wheat),Millet,Oatmeal and Whole-wheat bread, pasta or crackers.

Dairy

Aim for three to four servings of dairy foods a day. Dairy foods, such as milk, yoghourt and cheese, are good dietary sources of calcium, protein and vitamin D.

Foods to avoid in pregnancy

• When you are pregnant, you should reduce your intake of:
  foods that are high in sugar, such as chocolate, biscuits, pastries, ice-cream, cake, puddings and soft drinks. Sugar contains calories without providing any other nutrients, and can contribute to weight gain, obesity and tooth decay
• foods that are high in fat, such as all spreading fats (including butter), oils, salad dressings and cream. Fat is very high in calories, and eating more fatty foods is likely to make you put on weight. Having too much saturated fat can increase the amount of cholesterol in the blood, which increases the chance of developing heart disease.
• Foods that contain added salt. Don’t add salt in cooking or at the table.It can contribute to high blood pressure.

Exercise in Pregnancy:

Exercise is not dangerous for your baby. There is some evidence that active women are less likely to experience problems in later pregnancy and labour.The more active and fit you are during pregnancy, the easier it will be for you to adapt to your changing shape and weight gain. It will also help you to cope with labour and get back into shape after the birth.

As a general rule, you should be able to hold a conversation as you exercise when pregnant. If you become breathless as you talk, then you’re probably exercising too strenuously.

Stomach-strengthening exercises

As your baby gets bigger, you may find that the hollow in your lower back increases and this can give you backache. These exercises strengthen stomach (abdominal) muscles and may ease backache, which can be a problem in pregnancy:

• start in a box position (on all 4s) with knees under hips, hands under shoulders, with fingers facing forward and abdominals lifted to keep your back straight
• pull in your stomach muscles and raise your back up towards the ceiling, curling your trunk and allowing your head to relax gently forward. Do not let your elbows lock
• hold for a few seconds then slowly return to the box position
• take care not to hollow your back: it should always return to a straight/neutral position
• do this slowly and rhythmically 10 times, making your muscles work hard and moving your back carefully
• only move your back as far as you can comfortably

Pelvic tilt exercises

• stand with your shoulders and bottom against a wall
• keep your knees soft
• pull your tummy button towards your spine, so that your back flattens
• against the wall: hold for 4 seconds then release
• repeat up to 10 times

Pelvic floor exercises

• Pelvic floor exercises help to strengthen the muscles of the pelvic floor, which come under great strain in pregnancy and childbirth.).If your pelvic floor muscles are weak, you may find that you leak urine when you cough, sneeze or strain. This is quite common, and there is no reason to feel embarrassed. It’s known as stress incontinence and it can continue after pregnancy.You can strengthen these muscles by doing pelvic floor exercises. This helps to reduce or avoid stress incontinence after pregnancy. All pregnant women should do pelvic floor exercises, even if you’re young and not suffering from stress incontinence now.

How to do pelvic floor exercises:

• close up your bottom, as if you’re trying to stop yourself going to the toilet
• at the same time, draw in your vagina as if you’re gripping a tampon, and your urethra as if to stop the flow of urine
• at first, do this exercise quickly, tightening and releasing the muscles immediately
• then do it slowly, holding the contractions for as long as you can before you relax: try to count to 10
• try to do 3 sets of 8 squeezes every day: to help you remember, you could do a set at each meal.

Complications of pregnancy

• Some common complications of pregnancy include, but are not limited to, the following.
• High Blood Pressure
• Gestational Diabetes
• Infections
• Preeclampsia
• Preterm Labor
• Depression & Anxiety
• Pregnancy Loss/Miscarriage
• Stillbirth
• Other Complications-Severe, persistent nausea and vomiting

What is a high-risk pregnancy?

All pregnancies carry risks. The definition of a “high-risk” pregnancy is any pregnancy that carries increased health risks for the pregnant person, foetus (unborn baby) or both. People with high-risk pregnancies may need extra care before, during and after they give birth. This helps to reduce the possibility of complications.

 

What causes high-risk pregnancy?

• Factors that make a pregnancy high risk include:
• Preexisting health conditions.
• Pregnancy-related health conditions.
• Lifestyle factors (including smoking, drug addiction, alcohol abuse and exposure to certain toxins).
• Age (being over 35 or under 17 when pregnant).

(Credit:: High risk pregnancy- The economic times Jul 03, 2018)

What are common medical risk factors for a high-risk pregnancy?

• People with many preexisting conditions have increased health risks during pregnancy. Some of these conditions include:.
• COVID-19.
• Obesity.
• Diabetes.
• High blood pressure.
• Kidney disease.
• Thyroid disease.
• Mental health disorders, such as depression.
• Polycystic ovary syndrome (PCOS).
• Fibroids.
• Blood clotting disorders.
• Autoimmune diseases, such as lupus or multiple sclerosis (MS)

Pregnancy-related health conditions that can pose risks to the pregnant person and unborn baby include:

• Birth defects or genetic conditions in the unborn baby.
• Poor growth in the unborn baby.
• Gestational diabetes.
• Multiple gestation (pregnancy with more than one baby, such as twins or triplets).
• Preeclampsia and eclampsia.
• Previous preterm labour or birth, or other complications with previous pregnancies.

What are the signs and symptoms of high-risk pregnancy?

Talk to your doctor right away if you experience any of the following symptoms during pregnancy, whether or not your pregnancy is considered high-risk:

• Abdominal pain that doesn’t go away.
• Chest pain.
• Dizziness or fainting.
• Extreme fatigue.
• Your unborn baby’s movement stopping or slowing.
• Fever over 100.4°F.
• Heart palpitations.
• Nausea and vomiting that’s worse than normal morning sickness.
• Severe headache that won’t go away or gets worse.
• Swelling, redness or pain in your face or limbs.
• Thoughts about harming yourself or your unborn baby.
• Trouble breathing.
• Vaginal bleeding or discharge.

At what age is a pregnancy considered high risk?

People who get pregnant for the first time after age 35 have high-risk pregnancies. Research suggests they’re more likely to have complications than younger people. These may include early pregnancy loss and pregnancy-related health conditions such as gestational diabetes.

Young people under 17 also have high-risk pregnancies because they may be:

• • Anaemic.
  • Less likely to get thorough prenatal care.
  • More likely to have premature labour or birth.
  • Unaware they have sexually transmitted diseases and infections (STDs and STIs).

What are the potential complications of high-risk pregnancy?

A high-risk pregnancy can be life-threatening for the pregnant person or unborn baby. Serious complications can include:

• Preeclampsia (high blood pressure from pregnancy).
• Eclampsia (seizure from pregnancy).
• Preterm delivery.
• Excessive bleeding during labor and delivery, or after birth.
• Low or high birth weight.
• Birth defects.
• Problems with your baby’s brain development.
• Neonatal intensive care unit admission for your baby.
• Intensive care unit admission for you.
• Miscarriage.
• Stillbirth.

DIAGNOSIS AND TESTS

How is high-risk pregnancy diagnosed?

Getting early and thorough prenatal care is critical. It’s the best way to detect and diagnose a high-risk pregnancy. Be sure to tell your healthcare provider about your health history and any past pregnancies. If you do have a high-risk pregnancy, you may need special monitoring throughout your pregnancy.

Tests to monitor your health and the health of your unborn baby may include:

• Blood and urine testing to check for genetic conditions or certain birth defects in your baby.
• Ultrasonography, which uses sound waves to create images of your baby in the womb to screen for birth defects.
• Monitoring to ensure your unborn baby is getting enough oxygen, such as a biophysical profile, which monitors their breathing, movements and amniotic fluid using ultrasound, and a non-stress test, which monitors their heartrate.

 

TREATMENT

How is high-risk pregnancy managed?

Management for a high-risk pregnancy will depend on your specific risk factors. Your care plan may include:

• Closer follow-up with your obstetrician.
• Consultation with other medical specialists.
• More ultrasounds and closer fetal evaluation.
• Home blood pressure monitoring.
• Careful monitoring of medications used to manage pre existing conditions.

If your health or the health of your baby is in danger, your healthcare provider may recommend labour induction or a C-section.

PREVENTION

How can I prevent a high-risk pregnancy?

You can reduce your risk of pregnancy complications by:

• Identifying potential health risks before getting pregnant. Tell your doctor about your familial and personal medical history.
• Maintaining a healthy body weight before pregnancy.
• Managing any preexisting health conditions you may have.
• Making sure any long-term medications are safe to take during pregnancy.
• Planning pregnancies between the ages of 18 and 34.
• Practicing safe sex.

OUTLOOK / PROGNOSIS

What’s the prognosis (outlook) for people with high-risk pregnancy?

Many people who have high-risk pregnancies don’t experience any problems and deliver healthy babies. But they may be at a higher risk for health problems in the future, including:

• Complications during future pregnancies.
• Postpartum depression.
• High blood pressure.
• Cardiovascular disease.
• Type 2 diabetes.
• Stroke.

Some high-risk pregnancies can increase a child’s risk of:

• Behavioural problems.
• Breathing disorders.
• Gastrointestinal diseases.
• Growth and developmental delays.
• Mental health conditions.
• Neurological disorders.
• Obesity and diabetes.
• Vision, hearing or dental problems.

When should I contact my doctor?

It’s possible for pregnancy-related complications to occur up to six weeks after a pregnancy ends. Pay close attention to your health. Alert your healthcare provider right away if you notice anything abnormal.

 

Painless Delivery

What is Painless Delivery?

• Painless delivery can be achieved using a form of regional anaesthesia that provides pain relief during natural labour. Epidural anaesthesia is administered through an injection on the lower back of the mother. The drug takes about 10-15 minutes to take effect. This is a good option for women with a lower pain bearing capacity, who would otherwise opt for a C-section.

How is  epidural anaesthesia administered?

• You may be required to sit still with your back arched while you are given the epidural. The doctor will catheterize your lower back by inserting a thin tube into the lower part of your spinal cord. The needle is removed, and the catheter is taped into place so that the epidural anaesthesia can be administered during labour. The epidural is administered once you are in active labour and works by numbing your pelvic region and everything below it while you remain conscious. However, you should be aware that it does not offer 100% pain relief.

The advantages of epidural

• Painless delivery gives women a chance at experiencing natural childbirth, with very little intervention. It has helped in bringing down the number of elective C-sections in India.
• Women are given an option to take an epidural during labour if they feel they are not able to bear the pain, are exhausted from pushing or in case of any emergencies that may require an urgent C-section.
• By alleviating pain, it allows the mother to focus on the delivery. It is an aid for relaxation and can prevent exhaustion and irritation experienced by most women during childbirth, thereby reducing the risk of developing post-partum complications.
• It helps the baby descend easily by relaxing the pelvic and vaginal muscles.
• It also helps in lowering the blood pressure of the mother, which otherwise can shoot up to dangerous levels during labour.

The risks or side effects of epidural

• While the epidural is completely safe for the mother and the baby, it may leave you with side effects such as fever, breathing problems, nausea, dizziness, back pain and shivering.
• The new mother may experience severe migraine-like headaches due to some epidural leakage into the spine.
• The labour may take longer than otherwise when an epidural is used.
• The mother may have trouble passing urine after childbirth. In that case, a catheter may be used.
• It causes numbness of the entire lower body, and it may be a while before you can walk.
• In stray cases, if the mother’s blood pressure goes down, it may cause a lowering of heart rate in the baby as well. In extreme cases, an emergency C-section may be performed.

 

Complications during labor and delivery:

• Labor that does not progress. Sometimes contractions weaken, the cervix does not dilate enough or in a timely manner, or the infant’s descent in the birth canal does not proceed smoothly. If labor is not progressing, a health care provider may give the woman medications to increase contractions and speed up labor, or the woman may need a cesarean delivery.
• Perineal tears. Vaginal tears during childbirth, also called perineal lacerations or tears, occur when the baby’s head is coming through the vaginal opening and is either too large for the vagina to stretch around or the head is a normal size but the vagina doesn’t stretch easily. These kinds of tears are relatively common.

• Problems with the umbilical cord. The umbilical cord may get caught on an arm or leg as the infant travels through the birth canal. Typically, a provider intervenes if the cord becomes wrapped around the infant’s neck, is compressed, or comes out before the infant.
• Abnormal heart rate of the baby. Many times, an abnormal heart rate during labor does not mean that there is a problem. A health care provider will likely ask the woman to switch positions to help the infant get more blood flow. In certain instances, such as when test results show a larger problem, delivery might have to happen right away. In this situation, the woman is more likely to need an emergency cesarean delivery, or the health care provider may need to do an episiotomy to widen the vaginal opening for delivery.
• Water breaking early. Labor usually starts on its own within 24 hours of the woman’s water breaking. If not, and if the pregnancy is at or near term, the provider will likely induce labor. If a pregnant woman’s water breaks before 34 weeks of pregnancy, the woman will be monitored in the hospital. Infection can become a major concern if the woman’s water breaks early and labor does not begin on its own.

• Birth asphyxia. This condition occurs when the fetus does not get enough oxygen in the uterus or the infant does not get enough oxygen during labor or delivery or just after birth.

• Shoulder dystocia. In this situation, the infant’s head has come out of the vagina, but one of the shoulders becomes stuck.

 

 

• Excessive bleeding:
•  If delivery results in tears to the uterus, or if the uterus does not contract to deliver the placenta, heavy bleeding can result.
• It is called as “POSTPARTUM HAEMORRHAGE ” (PPH) is severe vaginal bleeding after childbirth.Postpartum haemorrhage is a medical emergency .Multiple specialist like gynaecologist, surgeons,anaesthesiologist, physicians and Intensivists teamwork required to manage the situation.Patient may require admission in ICU and ventilator support.Worldwide, such bleeding is a leading cause of maternal death.In India, PPH, which is exacerbated by widespread anemia among pregnant women, accounts for 38 percent of maternal deaths (RGI-SRS 2001-2003)

Causes:

• Tear in the cervix or tissues of the vagina.
• Tear in a blood vessel in the uterus.
• Bleeding into a hidden tissue area or space in the pelvis. This mass of blood is called a hematoma. It is usually in the vulva or vagina.
• Blood clotting disorders.
• Placental abruption. This is the early detachment of the placenta from the uterus.
• Placenta previa. This is when the placenta covers or is near the opening of the cervix.
• Overdistended uterus. This is when the uterus is larger than normal because of too much amniotic fluid or a large baby.
• Multiple-baby pregnancy
• High blood pressure disorders of pregnancy
• Having many previous births
• Prolonged labor
• Infection
• Obesity
• Being of Asian or Hispanic ethnic background

How common is postpartum hemorrhage?

• Postpartum hemorrhage occurs in about 1% to 10% of pregnancies.

How serious is postpartum hemorrhage?

• Postpartum hemorrhage is a serious and potentially fatal condition. With PPH, you can lose large amounts of blood very quickly. It causes a sharp decline in blood pressure, which can restrict blood flow to your brain and other organs. This is called shock, and it can lead to death. Postpartum haemorrhage is a medical emergency and needs to be treated with intensive care.

TREATMENT OF PPH

Resuscitation Rapid assessment & diagnosis  for PPH. IV fluid resuscitation, Manual removal of Placenta Parental Oxytocics & antibiotics: Blood transfusion AND Surgery.

• Multiple specialists like gynaecologist, surgeons,anaesthesiologist, physicians and Intensivists teamwork required to manage the situation.Patient may require admission in ICU and ventilator support.

More info https://www.nhp.gov.in/disease/gynaecology-and-obstetrics/postpartum-haemorrhage