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Newborn mortality rate (per 1000 live births) – 25
Annual reduction in newborn mortality rate 3.6% (2000-2016)
Preterm birthrate (per 100 live births) – 13
Maternal mortality ratio (per 100,000 live births ) 174
Source Healthy Newborn Network ; 2015 statistics

Welcome back to the second part of my blog Joyful Motherhood.
While I was practicing clinical obstetrics I used to counsel the husbands and parents on the pregnancy outcome such that all are well prepared.
Let us have a look at the frequently asked questions,

On exercise
The first three months can be a very physically tiring time for a pregnant woman due to the energy expended with changes occurring in her body and the development of a baby. There is need to listen to one`s own body and rest when one can. A brisk walk once or twice a week may be all that is needed. In the second trimester, many women tend to feel great. These women may well be able to change the exercise program during this period, and adjust to a rhythm that is comfortable for their bodies.

During the last three months called the third trimester, women may feel more fatigued with the weight of their growing baby. This is the time for gentle walks, stretching and catching up on some rest. A pregnant woman can manage all house hold activities including scrubbing the floor during the first six months.This will give more laxity to pelvic bones and facilitate normal delivery.

On Ante natal care
This can be done by any basic doctor or a well trained midwife. Ante natal care is planned to have an idea about the health of the woman and anything that can affect the baby. Each visit should be a question answer session to build up the confidence of the patient on the doctor and vice versa. Urine and blood pressure and weight gain is checked. Weight gain should be on average 9-13 kg during the pregnancy period. An abdominal examination is also done to ascertain the position of the baby and the size of the uterus carrying the baby to rule out any small or big baby or twins. A scan is done in the second month to confirm whether the baby is inside the uterus, another in the third month to confirm singleton or multiple pregnancy. A scanning is done at fifth month to rule out neural tube defects and at 7-8th month to confirm the position of placenta.All other sophisticated tests are not required as a routine. These may be done at the instance of the Obstetrician if indicated as a special case. A blood test is done to rule out anaemia, and blood grouping in the event of the requirement of blood transfusion. Screening for Hepatitis, Rubella anti body and HIV screening are all optional.

For screening for foetal anomaly-A detailed ultrasound scan (anomaly scan) at 20 weeks. This looks for major physical abnormalities. There are however, limitations to the accuracy of the scan.

On the diet

There is no need for any extra food in pregnancy. It is a common myth that you should eat for two. In fact most women do not need extra calories for the first 6 months of pregnancy and only require approximately 200 extra calories per day during the last 3 months.

However, because the blood sugar levels fluctuate more due to the extra demands on the body, it is important to eat regularly, including snacks between meals. Most women gain between 9 – 13 kg during pregnancy, although this can vary from woman to woman. You should never try to diet during this period as you could be depriving the baby of vital nutrients.
The best thing to do throughout pregnancy is to eat a variety of healthy foods. They should contain certain key components necessary for growth and development. These include foods containing iron (e.g. green leafy vegetables, red meat, beans and pulses although additional iron supplements may also be given to you by your doctor); calcium (e.g. dairy produce, fish with edible bones like sardines and bread) and folate (e.g. green beans, oranges, spinach, kale or broccoli).

On Vitamin, Calcium and Iron

Folate is a B vitamin crucial in the development of baby’s nervous system. It has been shown to reduce the chance of having a baby with a neural tube defect (a disability affecting the nervous system). Folate is easily destroyed during cooking and large servings are necessary for adequate intake. The simplest way is to take a folate supplement (one 5 mg tablet daily) for the first 12 weeks of pregnancy. Folate is particularly important if one suffer from epilepsy, thalassaemia or have a family history of having relatives with a neural tube defect. One Calcium and Iron tablet each can also be consumed daily. Have enough fluids and one should also reduce the intake of tea, coffee and cola as the caffeine content of these drinks will affect the vitamins in the food, particularly Vitamin C and also Iron. Develop a habit of taking a fruit juice instead of Coffee /Tea.

On Sex
There is no reason why pregnant women cannot have a fulfilling sex life. In fact, the pregnancy hormones may make you feel more responsive. As the woman get bigger, she may want to experiment with different positions to find one that is comfortable. If she has suffered from any early bleeding, premature labour or have a low-lying placenta, it is wise to consult the doctor who may suggest a period of abstinence.

On Drugs
Avoid intake of any drugs from any system of medicine from 28th day of conception to sixtieth day unless and until they are absolutely indicated.The date of conception will normally be between 10th to 15th day of last menstrual period. This period is very crucial as organogenesis occurs during this period. A ball like fertilized egg called Zygote turns into a foetus during this period. Unnecessary drug intake can result in the defect in the organ that is likely to develop during the dates when the drugs are taken.

The Warning Symptoms Of Adverse Events In Pregnancy
In early pregnancy light spotting or bleeding is due to implantation which occurs when the embryo is attached to the womb. This is a normal phenomenon. However continued bleeding requires clinical examination. Similarly light bleeding with blood-stained mucus in the month before the baby is due could be a ‘show’ — a sign that the woman may go into labour within the next few days or week. However painless heavy bleeding and any amount of bleeding with severe pain also warrants clinical examination. Another warning symptom is feeling dizzy with , nausea and vomiting, blurred or double vision which often herald hypertensive disorders from pregnancy. This requires continued monitoring of blood pressure and albumin in the urine and swelling over the legs.

Babies are most active when the woman is at rest. This is because she is now more aware of their movements. Hence she will notice frequent movements in the evening or at bedtime. There should be at least 10 “kicks” over a 12-hour period. Conversely an active baby is reassuring and excessive movements are not cause for worry. If the kicks become lesser a scanning may be required.

Normally the water-bag where the baby floats in t he uterus is ruptured (either spontaneously or by the obstetrician) when labour begins. Rupture of the water-bag before the onset of labour is associated with increased risk to the baby. Complications include infection or prolapsed of the umbilical cord through the cervix. If she feel a sudden gush or continuous flow of clear fluid from the vagina, an obstetrician should be consulted.

I am sure if the woman is under the care of a trained doctor/midwife they can easily pick out these problems and initiate required management processes.

Remember always that 60% of pregnancies can occur without any help, only 40% require some assistance and only 15% require surgical interventions. This doesn’t mean that 60% need not have any help. The main issue is that only after the delivery will one know in which group they belonged?

Labour -the process of child birth begins with regular, painful uterine contractions or tightening of the abdomen, ‘bloody show’ (blood-stained mucus) or ‘breaking of her waters’ (rupture of your membranes). This usually occurs at term, after 37 weeks of pregnancy. Preterm labour occurs when these signs are present before 37 weeks.

The idea behind this article is awareness generation on Safe delivery and for avoiding undue tension and stress during pregnancy. I have included only some of the danger signs in Pregnancy and Child birth. My intension is not to load one with lot of materials that may not be much relevance .

Be under the care of a well trained midwife who is very patient or a well trained family doctor. Forget all the tension and stress. Pregnancy problem are always individualistic and not much attention need be given to what the print and visual media churns out. Remember that media are more interested in circulation and number of viewers their product can attract.

The estimated date of delivery is often calculated by adding 9 months and 7 days to the first day of the last menstrual period. These dates are all calculated assuming that you have a standard 28 day cycle and the number of weeks also includes the first 2 weeks of your menstrual cycle, when you are technically not pregnant. If your cycle varies from this and you know when you ovulated (mid period with signs like lower abdominal pain and increased discharge of thick vaginal mucus), just work back 2 weeks from this date to find your last menstrual cycle date (LMP). Knowing when you are due can help you plan your important appointments for your antenatal care and lots more. Just remember, it’s not mandatory that the woman will be delivering on the estimated day. Baby will come  when it is ready. The majority of babies are born within 2 weeks either side of their EDD.

Have a safe and Joyful pregnancy

An alumnus of Trivandrum Medical College (1965-70) Dr N S Iyer is a senior Obstetrician and Gynecologist and retired Deputy Director of Kerala Government Health Services. Post retirement he became the Project officer in UNICEF, Chennai office, in charge of the Maternal and Child Health Programme in Tamil Nadu and Kerala.

If you have any pregnancy related queries for Dr.Iyer  write to us at marketing@pmsind.com

A retired Gynaecologist in a senior citizen meeting milieu serves as the catalyst for the discussion to veer toward problems faced by women during pregnancy and how doctors prefer to do Caesarean Section (C-Section) . Having served as an Obstetrician in Kerala Government Health services for three decades, I argue with them sharing my own clinical experience and opine that C-section rates need not be more than 15% and that only 40% of pregnant women face some problem during final stages of pregnancy. More important, pregnancy should be considered a joyful process.

But melodramatic movies that depict a shrieking mother-to-be writhing in pain as well as all other women’s tales of pain makes the situation worse. As a result more women request doctors for a C-Section, not realizing that regardless of the procedure adopted, the child feels some pain in the process. Since now I am now involved the field Of Social Obstetrics, focusing on quality of care in Obstetric services, I thought it might be worthwhile to share my opinion about the concept of preparation for a child birth.

Pregnancy is a normal physiological process and if any complications arise, these are usually due to some unresolved issues. The point to note is that pregnancy is not a disease.“An occasion so momentous and a marvel so beautiful has however always been shrouded in myths , old wives’ tales and also pain for all those who don’t know. What is ironic to note is that even advancements in science and increasing education levels haven’t done much to alleviate the doubts and fallacies surrounding child birth. 

You would be amazed that even with such high levels of education and exposure, young girls have gross misconceptions about child birth” says Dr Sushma Neharai the world record holder for delivering a 5.7 Kg baby through normal delivery.

For a normal pregnancy and delivery, a regular check up is all that is required to ensure that everything is well. This can be done by an ordinary doctor or a well trained midwife. However, pregnancy complications are always unpredictable but curable if detected on time. Further, the instances of complicated pregnancies can be saved by timely referral to institutions with all required facilities.

On an average 28-30 million deliveries take place annually in India. This is nearly 75000 a day across India.

What is required for a routine checkup is a well trained and caring midwife doing the ante natal check and labour being arranged in a facility where 24 hour obstetric care services by a qualified well trained doctor is available. Availability of a trained doctor /midwife having patience, masterly inactivity and watchful expectancy are the requirement of a normal delivery and not star studded hospitals with intensive care units and obstetricians of repute and those with the so called kai rasi.(Kai punniyam).

The misconception that all pregnancies end in C section is an offshoot of “my daughter/my wife should not experience pain during labour” syndrome. In cases where the parents /husbands do not have confidence in the doctor and if the confidence level of doctor is sub optimal, there may be instances of unnecessary C-Sections

Whenever I start my lecture on Maternal Health, I always state complications in a pregnancy can arise anytime. This in spite of the reputation of the obstetrician involved, having daily check ups with all required tests etc. Even if a mother-to-be is found to be normal until the time of delivery, a complication can still occur depending on various conditions. The higher the reputation of an obstetrician ,more will be the number of pregnancies she may be forced to manage and it will be impossible to get personal attention. Sometimes, the doctor may not be available at the time of delivery and the poor woman may be seeing strangers when she requires affectionate, patient observation and masterly management at the time of child birth.

Having said that, pregnancy is still a normal physiological process, and as two lives are involved there are certain common facts every pregnant woman, husbands and parents ought to be aware of . While I was practicing clinical obstetrics I used to counsel the husbands and parents on the pregnancy outcome such that all are well prepared.

Stay tuned for my next post on common facts for every pregnant woman, husbands and parents.
An alumnus of Trivandrum Medical College (1965-70)

Dr N S Iyer is a senior Obstetrician and Gynecologist and retired Deputy Director of Kerala Government Health Services.
Post retirement he became the Project officer in UNICEF, Chennai office, in charge of the Maternal and Child Health Programme in Tamil Nadu and Kerala.

Baby’s stay in NICU can be stressful and emotionally taxing. Mother’s often miss the initial bonding and feeding. It is really important to feed term or pre-term babies with breast milk after they are born. If mother’s can’t breastfeed directly to ill or preterm babies then mother’s have choice to express their milk instead of feeding formula milk.

What makes breast milk so special?

Breast-milk is a unique fluid containing essential nutrients – anti-infective factors, hormones, enzymes, specialized growth factors, anti-inflammatory mediators, specific nutrients. There are various studies stating importance of breast milk for term as well as preterm babies. Recognizing the importance, Unicef and WHO in 1990 came up with Innocenti declaration stating infants should be fed breast milk up to 4 to 6 months. This provided ideal nutrition transfer – helped in reduction of neonatal morbidity.

 

Breast milk for premature babies

Premature babies spend comparatively lesser time in womb, depriving of basic nutrients required for growth. They are easily susceptible to illness and stunned growth. For first few weeks- mother’s of premature babies secrete milk with higher fat, proteins, minerals and antibody ( immunoglobulin G) required for their growth.

Premature babies face issues of improper digestion. Antibody and enzyme also help in intestinal digestion making preemies less susceptible to intestinal infections.

Prof. Peter Hartmann founder of Human lactation research group in Australia says,”Every drop counts”. A premature baby is likely to recover faster from illness and sepsis when fed with breast-milk.

 

Facts on Breast-milk:

• Breast milk is the first choice in neonates, whether term or preterm.
• There are significant clinical benefits to providing breast milk in the preterm infant.
• Expressed breast milk can be frozen for later use.
• Human milk fortification should be considered in babies with a birth weight of < 2000 g.

 

Skin – to -skin contact

Once your baby is ready to be held, gradually shift from tubes to breast feeding. Caring for and learning to breastfeed a premature or ill newborn is emotionally taxing for any new mother. Ask for help from nicu nurses to first initiate. It usually takes sometime for baby to latch. Gradually as they develop and get stronger, they will be able to breastfeed directly. During breastfeed, skin to skin contact promotes warmth and bonding between mother and baby.

 

Benefits of breast-feeding moms

Lot of mothers who breastfeed feel fulfillment and joy with physical and emotional bonding. Hormones like prolactin and oxytocin are secreted releasing strong sense of nurturing and bonding between mother and baby. There are recent studies stating breastfeeding reduces risks of breast and ovarian cancer.

At home

Once baby is home from hospital, breastfeeding can be continued till 4-6 months. Later stages, mothers can express breast milk and store, especially when baby grows and need increases. Additionally, emotional and practical support from loved ones goes extra mile to support new moms.

 

Ref:

http://humanlactationresearchgroup.com

https://www.unicef.org/programme/breastfeeding/innocenti.htm