Obstetric Care

ANTENATAL CARE

Prenatal care (also known as antenatal care) refers to the regular medical and nursing care recommended for women during pregnancy. Prenatal care is a type of preventative care with the goal of providing regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy while promoting healthy lifestyles that benefit both mother and child. During check-ups, women will receive medical information over maternal physiological changes in pregnancy, biological changes, and prenatal nutrition including prenatal vitamins. Recommendations on management and healthy lifestyle changes are also made during regular check-ups. The availability of routine prenatal care has played a part in reducing maternal death rates and miscarriages as well as birth defects, low birth weight, and other preventable health problems.

Acme Fertility have wholesome maternity care unit at same palce as IVF lab, so as to provide an excellent antenatal care to you. For us every pregnancy is a precious pregnancy, we do care you and your little one till the birth and even thereafter.

Prenatal care generally consists of:

• Monthly visits to the doctors during the first two trimesters (from week 1–28)
• Fortnightly visits to doctor from 28th week to 36th week of pregnancy
• Weekly visits to doctor after 36th week till delivery(delivery at week 38–40)
• Assessment of parental needs and family dynamic.
• Detection of risk factors and its management.
• Care for pregnancies with previous history of complications.

a) Physical examinations generally consist of

• Collection of (mother’s) medical history
• Checking (mother’s) blood pressure
• (Mother’s) height and weight
• Pelvic examination
• Doppler fetal heart rate monitoring
• (Mother’s) blood and urine tests
• 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:

• Diagnose pregnancy
• Check for multiple fetuses
• Assess possible risks to the mother (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition)
• Check for fetal malformation (e.g., club foot, spina bifida, cleft palate, clenched fists)
• Determine if an intrauterine growth retardation condition exists
• Note the development of fetal body parts (e.g., heart, brain, liver, stomach, skull, other bones)
• Check the amniotic fluid and umbilical cord for possible problems
• Determine due date (based on measurements and relative developmental progress)

• Complete blood count (CBC)
• Blood type
• General antibody screen (indirect Coombs test) for HDN
• Rh D negative antenatal patients should receive RhoGam at 28 weeks to prevent Rh disease.
• Rapid plasma reagin (RPR) to screen for syphilis
• Rubella antibody screen
• Hepatitis B surface antigen
• Gonorrhea and Chlamydia culture
• PPD for tuberculosis
• Pap smear
• Urinalysis and culture
• HIV screen
• 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 :

• Hematocrit (if low, mother will receive iron supplementation)
• 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,[10] 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:

• Fetal karyotype can be used for the screening of genetic diseases. This can be obtained via amniocentesis or chorionic villus sampling (CVS)
• 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.
• 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.
• Nonstress test (NST) for fetal heart rate
• Oxytocin challenge test

G) Complications & Emergencies :

The main emergencies include

• 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.
• 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).
• Placental abruption where the patient can bleed to death if not managed appropriately.
• Fetal distress where the fetus is getting compromised in the uterine environment.
• Shoulder dystocia where one of the fetus’ shoulders becomes stuck during vaginal birth, especially in macrosomic babies of diabetic mother.
• 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.
• 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.

• 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
• Systemic lupus erythematosus and pregnancy confers an increased rate of fetal death in utero and spontaneous abortion (miscarriage), as well as of neonatal lupus
• 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.
• 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

• Pessary of Prostin cream, prostaglandin E2
• Intravaginal or oral administration of misoprostol
• Cervical insertion of a 30-mL Foley catheter
• Rupturing the amniotic membranes
• 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:

• 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)
• Accelerate the progress of labor by infusion of the hormone oxytocin
• Provide pain relief, either by nitrous oxide, opiates, or by epidural anesthesia done by anaesthestists, an anesthesiologist, or a nurse anesthetist.
• Surgically assisting labor, by forceps or the Ventouse (a suction cap applied to the fetus’ head)
• 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

• General Condition of the patient.
• Check for Vital Signs (Pulse, Blood Pressure, Temperature, Respiratory Rate, (Pain) at times)
• Palor, Edema, Dehydration, Lochia (colour, amount, odour)
• Fundus (height following parturition, and the feel of the fundus) (Per Abdominal Examination)
• If an Episiotomy or a C-Section was performed, check for the dressing. Intact, pus,
• Bladder (keep the patient catheterized for 12 hours following local anaesthesia and 24–48 hours after general anaesthesia) (check for bladder function)
• Bowel Movements
• 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

• Women whose physical and/or mental health were endangered by the pregnancy
• Women facing the birth of a potentially handicapped or malformed child
• Rape
• Pregnancies in unmarried girls under the age of eighteen with the consent of a guardian
• Pregnancies in “lunatics” with the consent of a guardian
• 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) Methods

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

• Smoking > 35 years
• Anemia – hemoglobin < 8 gm %
• Suspected /confirmed ectopic pregnancy / undiagnosed adnexal mass
• Coagulopathy or women on anticoagulant therapy
• Chronic adrenal failure or current use of systemic corticosteroids
• Uncontrolled hypertension with bp >160/100mmhg
• Cardio-vascular diseases such as angina, valvular disease, arrhythmia
• Severe renal, liver or respiratory diseases
• Glaucoma
• Uncontrolled seizure disorder