Obstetric Conditions

Antenatal care includes regular medical visits, screening tests, and diagnostic tests to help assess your health status to keep you and your baby in a healthy condition during your pregnancy. The routine visits to the doctor are scheduled so that any problems present may be recognised and treated well in advance. These visits also educate you on handling various aspects of your pregnancy. Your doctor will discuss about healthy eating, activity, screening tests necessary and what can be expected during labour and delivery.

There are several antenatal tests to assess development of the baby in your womb. Antenatal tests are done at a stipulated time beginning from 8-10 weeks of gestation through 20 weeks. Prior to a test, counselling is done which will assist you in deciding the type of test based on advantages and disadvantages of each.

What are the tests involved in antenatal screening?

Antenatal screening tests such as ultrasound, first trimester and second trimester screening are done to determine whether your baby is at any risk of having a genetic condition such as Down's syndrome or other abnormalities. You should have antenatal screening done particularly if you have the following conditions:

• One of your near relatives or your previous child has a serious genetic anomaly
• If you or your partner are "carriers" of a faulty gene
• You are in your mid 30's or older
• Long term exposure to chemical or other harmful environmental agents

However, irrespective of your age or family history, it is always better to have the antenatal screening tests done.

First trimester screening: The first trimester screening is done between 11 weeks and 14 weeks of gestation and includes blood tests and an ultrasound examination. It is done to detect the risk of abnormalities such as Down's syndrome and trisomy 18. The blood tests determine the level of pregnancy-associated plasma protein-A and human chorionic gonadotropin in your blood. Nuchal translucency screening test, ultrasound examination, is done to measure the thickness of the back of the foetal neck. Large space or increased space indicates Down's syndrome, trisomy 18 or other chromosomal abnormalities. Your doctor may suggest for a more detailed examination at around 20 weeks of pregnancy, if first trimester screening tests are positive.

Second trimester screening: During this period, multiple marker screening is done to screen Down's syndrome, trisomy 18 and neural tube defects. The test measures the concentration of alpha-fetoprotein and hormones estriol, human chorionic gonadotropin, and inhibin-A in the mother's blood. These tests are done between 15 and 20 weeks of gestation.

Combined screening: The combined reports of the first and second trimester may yield more useful information about the diagnosis of Down's syndrome.

If the screening tests indicate a problem in the baby, further diagnostic tests such as detailed ultrasound, amniocentesis, and chorionic villus sampling and cordocentesis may be done to check whether the baby actually has a defect.

After the screening, if your baby is found to have an increased risk for developing a chromosomal abnormality or if a problem is detected with diagnostic testing, genetic counselling will support you with further decisions. Genetic counselling provides you the chance to discuss the following issues:

• Outcome of the results of antenatal tests
• Options available
• Further testing, its advantages and disadvantages
• Course of action that can be taken

Gestational diabetes

Your doctor will check your blood glucose level to rule out gestational diabetes, if you are at high risk of developing diabetes during pregnancy. You may need one or more of the following tests depending on your risk:

• Fasting blood glucose or random blood glucose test
• Screening glucose challenge test: You will be given a sugary liquid to drink and after an hour, your blood glucose level is checked. If the result is normal, then further tests are carried out.
• Oral glucose tolerance test: This test requires certain special instructions to be followed before the testing. It includes eating a normal diet for 3 days, followed by fasting for at least 8 hours before the test.

The blood glucose level will be measured before the test. Then after drinking a sugary beverage, the blood glucose levels are noted after 1, 2 and 3 hours. If your blood glucose level rises above normal at least twice during the test, then gestational diabetes is confirmed.

If gestational diabetes is confirmed your obstetrician may recommend diet, exercises and certain medications. Also, you and your baby will be more closely monitored throughout the pregnancy. Uncontrolled gestational diabetes may cause further problems during delivery such as need for C-section, large sized baby, hypoglycaemia (low blood sugar) in newborn or even a possibility of the woman developing diabetes after the delivery.

Birthing, also called labour or parturition is the act or process of giving birth to offspring. Every woman's labour is different, even from first pregnancy to the next.

What are the stages of birthing/labour?

The process of normal child birth is categorized into 3 stages of labour:

First stage: This stage commences with dilation and thinning of your cervix to allow the baby to reach the end of the birth canal. This stage is usually the longest part of the labour and is further divided into early labour and active labour.

• Early labour: In early labour your cervix may dilate and you may experience mild to moderate contractions lasting for 30 to 90 seconds. A thick, stringy, blood-tinged liquid may discharge through the vagina. The duration of early labour is unpredictable, but can be longer for a first delivery and shorter for subsequent deliveries.
• Active labour: During active labour your cervix dilates more rapidly and the contractions are stronger, closer together and may last longer. The transition phase is considered as the last part of active labour.

Second stage: This stage is the birth of your baby and usually lasts from a few minutes up to several hours depending on the position of the mother and the baby. During this stage, your cervix is fully dilated, uterine contractions become more frequent and you feel a strong urge to push. With each contraction, you may be encouraged to push to speed up the process. You may be asked to withhold some pushes to help prevent tears in the vaginal tissues. After your baby's head emerges the airway will be cleared and the umbilical cord is clamped and cut. The rest of the baby's body is delivered soon after the head.

Third stage: During this stage the placenta, an organ connecting the uterine wall and the foetus, is expelled. Gentle uterine massage may help to release the placenta. The placenta should be intact and any remaining parts within the uterus should be removed to prevent bleeding and infection.

What are the complications involved?

The complications of the birthing process include:

Weak contractions: Weak contractions can make the mother exhausted and can cause foetal distress. Foetal distress occurs when there is lack of oxygen. Improper or weak contractions may be caused by rigid or oedematous cervix.

Passage obstruction: Difficult labour may occur when the birth passage is obstructed by tumours, cysts, fractures, and physiological changes such as degenerative joint disease.

Abnormal presentation of the foetus: Abnormal position of the foetus could be either upside down or breech (buttocks down) position. In face presentation, the baby's face is leading with the neck in extension. In shoulder presentation, the shoulder, arm or trunk may present first and this type of presentation is more common in multiple pregnancies.

Forceps delivery: In this type of delivery forceps are used to grasp the foetal head. Use of improper forceps technique can result in injury to the foetus.

Caesarean Section: It is a surgical procedure of delivering a baby though an incision in the lower abdomen. Caesarean section is indicated in foetal distress, maternal (mother) distress, abnormal position of the foetus, and narrow birth passage.

Birthing is the act or process of giving birth to offspring. Labour or childbirth experience may differ in every woman. Common initial signs of labour include strong regular contractions, backache, draining of water (amniotic fluid) or sticky and mucous-like substance through the vagina. The average time for which you will be in labour may be approximately 12-18 hours. The most common risks and complications that may occur during labour are discussed below:

Preterm Labour

Preterm labour is said to have occurred when you have strong contractions before 37 weeks of your pregnancy whereas the gestation period normally is 38 to 40 weeks. A baby if born prematurely will be at risk of complications such as immature lungs, respiratory distress, and problems in digestion as the organ systems would not have developed completely to support survival.

Your doctor will manage this situation with medications that stop labour or prevent infection. Also, medications that accelerate the baby's lung development may be given. You will be advised to take bed rest usually lying on the left side.

Prolonged labour

Some women, most often during their first pregnancy, may go through a labour that lasts for too long. Prolonged labour may lead to infection in case the amniotic sac has ruptured. Anti-infective medications may be administered to prevent infection.

Abnormal Presentation

During labour, the baby normally moves to a head-down position with the back of the head ready to enter the pelvis. Sometimes, the baby may present with buttocks or feet first towards the birth canal. This is called breech presentation. In some conditions, the placenta may block the cervix (placenta previa) and cause abnormal presentation.

Abnormal presentation increases the risk of injuries to the uterus or birth canal as well as the foetus. Breech presentation may lead to a prolapsed umbilical cord which can cut off the blood supply to the foetus. Your doctor will check the presentation and position of the baby with physical examination and ultrasound scan. Assisted delivery methods may be adopted in such cases.

Premature Rupture of Membranes

Rupture of the membranes that surround the foetus in the uterus may occur prematurely leading to high risk of infection. In these cases, immediate delivery of the foetus will be done.

Umbilical Cord Prolapse

The umbilical cord which transports oxygen and nutrition to the baby may slip into the cervix before the baby during labour. The cord may be felt if it protrudes from the vagina. This is an emergency as the blood flow to the baby through the umbilical cord may get obstructed.

Umbilical Cord Compression

During labour, the umbilical cord may get compressed leading to decreased blood flow to the foetus. This causes abrupt drop in the foetal heart rate. In cases where the foetal heart rate has worsened or there are signs of distress, your doctor may consider a Caesarean section.

Amniotic Fluid Embolism

Amniotic fluid embolism occurs when a small amount of amniotic fluid from the amniotic sac enters your bloodstream during a difficult labour. This fluid may travel up to the lungs and cause constriction of the lung arteries leading to a rapid heart rate, irregular heart rhythm, cardiac arrest and death.

Postnatal Tips for the New Mother

The postnatal period begins after the delivery of the baby and lasts for six to eight weeks. During this time, a new mother undergoes many physical and emotional changes, and learns to care for her newborn. A new mother should also take good care of herself to restore her strength. Read more

Pregnancy planning involves talking to your doctor prior to becoming pregnant.  The planning process helps create a healthy environment for the foetus, can prevent birth defects as well as other pregnancy related problems. It involves assessing you for any illness or pre-existing diseases which may affect the pregnancy and delivery of a healthy baby. Although many women have normal pregnancies, pre-planning with your physician improves the chances of a smooth pregnancy and a healthy baby.

What issues can be addressed prior to pregnancy?

Some of the issues addressed by obstetricians in pregnancy planning include:

• Medical conditions: A thorough medical examination before pregnancy helps in diagnosing any medical conditions that may affect the mother and baby such as diabetes, high blood pressure, anaemia, kidney disorders, thyroid diseases, and heart problems. Your physician will advise you on certain measures to control them.
• Infections and vaccinations: During pregnancy, the mother will be more susceptible to infections which can cause serious birth defects or illness in the baby. Tests are done to determine immunity against diseases such as measles and chicken pox. If the expecting mother lacks antibodies against these diseases, then the doctor will advise to get vaccination before pregnancy.
• Immunisation: If the mother is a carrier of hepatitis-B virus, blood tests will be done to identify the virus and the child will be vaccinated at birth. Vaccination protects the foetus from hepatitis-B infections.
• Medications: Women who are infected with human immunodeficiency virus (HIV) will be advised to take certain medications during pregnancy to decrease the risk of the foetus becoming infected with HIV.
• Hereditary disorders: In women with a family history of hereditary disorders such as haemophilia, sickle cell anaemia, cystic fibrosis, and thalassemia, the chances of a child developing these conditions is increased. Therefore, before planning for pregnancy your doctor may suggest both mother and father undergo certain tests to identify these diseases.
• Diet: Practicing a healthy diet is very important before pregnancy. Your doctor may suggest changes in your diet and including supplements such as prenatal vitamins and folic acid. Your doctor will also advise to avoid alcohol, tobacco, and drugs as they may affect the baby in harmful ways.

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Prenatal service is that extra care given to you for a healthy and safe pregnancy. Prenatal services include patient education, regular visits, planned nutrition & diet instruction. It also includes certain measures you need to practice ensuring a healthy and safe pregnancy.

What are the common prenatal service measures?

Listed below are some of the common measures:

• Maintain a healthy balanced diet with nutrition rich whole foods that help your baby's development. Your doctor may suggest nutritional supplements you need to take during pregnancy such as preparations containing calcium, iron, and folic acid.
• If you are taking medications, including over the counter medicines, for any disorders make sure to discuss them with your obstetrician because certain types of medications may cause birth defects.
• Regular exercises are beneficial during pregnancy, however overdoing it may pose certain complications. Walking and swimming are preferred physical activities. Talk to your obstetrician about your current exercise program to see what is right for you.
• During pregnancy you should avoid smoking, taking habit-forming drugs such as heroin, cocaine, caffeine containing preparations and alcohol as there is an increased risk of miscarriage, premature birth, or delivering a low birth weight infant.
• Avoid sitting in a sauna bath or hot tub as heat increases the risk of miscarriages and birth defects.
• Sleep on your left side to prevent pressure on the large blood vessels from the weight of the baby.

Wear comfortable clothes and avoid tight clothing to prevent varicose veins, haemorrhoids, and swelling in your legs.

The pregnancy calculator will help you find out when your baby is due, how many weeks you are, and how big your baby is based on the date of your last menstrual period and average cycle length.

Some women may want to take a more active role in their birth and if so Dr Brown offers a Maternally Assisted Ceasarean Section where the surgical drape is dropped down and you pull baby straight up to you for that important skin to skin contact. Also delayed cord clamping can be done. Obviously some higher risk situations and most Emergency Ceasareans will preclude this for the sake of safety but feel free to ask Dr Brown about the possibilities!

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