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Changing Concepts of Antenatal Care

Sep 27 | 12:30 PM

To achieve full potential that ANC promises, a package often called focused antenatal care is required. Let's understand all the essential interventions in ANC including identification and management of infections to required course supplementation. ANC is also an opportunity to promote the use of skilled attendance at birth and healthy behaviors such as breastfeeding, early postnatal care, and planning for optimal pregnancy spacing. Many of these opportunities continue to be missed, even though over two-thirds of pregnant women receive at least one antenatal visit. Let's understand how can we strengthen ANC to provide the priority interventions, especially given India's current shortage of human resources for health!

[Music] uh good evening everyone i'm dr nivedita from netflix and um from team netflix i welcome you all to today's session on um changing concepts of antenatal care we have with us here dr swati gawai she is an assistant professor of obstetrics and gynecology at um lochmania the luck multiple medical college and hospital thank you thank you for this introduction so today we'll be talking on changing trends of antenatal care as we all know antenatal care is a comprehensive health supervision of a woman pregnant woman before delivery or till delivery so it includes the examination which is very planned one it includes observation and guidance given to the pregnant woman from conception till the time of labor so is it for is it only for doctors no it is also for antenatal women their families their partners and various commissioners of antenari care services so what are the goals the goals are actually to reduce maternal and perinatal mortality and morbidity rates so it improves the physical and mental health of women and children as well so why these goals are set these goals are said to ensure that pregnant woman and her fetus are in the best possible health it detects early and treat any complications if at all are there so it offers education for parenthood it prepares the woman for labor lactation and care of the infant so we have to discuss with the couple about the place time and mood of delivery it motivates the couple for family planning and also provides various measures available for for family planning so when is it to be started it can be started in a straightforward ways depending on woman's need and for circumstances either she can come walk in or she can be referred by general practitioner made by free or any other health care professional or through school nurse community centers and hostels also so what do we have to do we have to keep a referral form or a sheet to offer early pregnancy health and wellbeing of information or information booklet we can say before booking appointment this includes information about modifiable factors that may affect the pregnancy it includes stopping smoking any other uh like avoiding alcohol or any other addiction taking supplements and eating healthy food so we ensure that the materials are available in different languages since india is a multi-linguistic country we have various languages so all it should be available in whatever language according to the local area or if the woman is blind then we can use braille lipy also so the referral form it enables the healthcare professional to identify women with specific health condition and social care needs the risk factors including those that can be potentially addressed before the booking appointment for example smoking or any other addiction it includes the contact details of the female as well as the partner or the family so how are the antenatal appointments planned the first visit or the initial visit should be made as early as possible in pregnancy as the pregnancy is diagnosed or at least by 10 weeks of gestation if a woman works late in pregnancy then ask about the reason for late booking because sometimes it may be related to social psychological or medical issues that need to be addressed so visits actually for 28 weeks at least every month after that twice in a month after that four times in a month till labor so in overall in an ali paris woman at least with an uncomplicated pregnancy we schedule at least 10 appointments for a multiparous at least seven appointments with an uncomplicated pregnancy so what do we do in routine antenatal care we do an assessment assessment on the basis of history examination and investigations so in history we have to ask about the personal history everything personal history regarding sleep diet any addiction any past family family history any past history of surgery or medical disorder like cardiac disorder or respiratory disorders menstrual history whether it was irregular regular menorah or previous obstetric history like previous cesarean section or any previous complication during pregnancy placenta previa or any other high risk condition and history of this pregnancy so this current and recent medicines within including the over the counter medicines health supplements many women they take iron folic acid and calcium on their own in india many women also prefer taking herbal medicines so we have to ensure what medications the woman is taking also we have to ask for allergies for her occupation uh discussing any risk regarding occupation like as in doctors i can very well in last one year or one and a half year we have noticed that coverage is more we all as a doctor are very high risk for covid so occupation we have to ask or in staff nurses also and everybody health care workers so also we have to ask for the family and home situation whether she is having a good support network at home any health issues regarding her or her partner or any family family member that may be significant for our health health and well-being so other people who may be involved in the care of the baby like usually mother or mother-in-law contact details of the mother or the next of the king factors such as nutrition diet physical activity smoking tobacco use alcohol consumption and recreational drug uses so at every antenatal appointment we have to carry out the risk assessment so what what do we have to ask we have to ask the woman about her general health and wellbeing whether if she is feeling well or not as the woman or if partner is also present after ask if they have any concerns or if they want to would like to discuss anything provide a safe environment and opportunities for them to discuss topics such as concerns at home domestic abuse concerns about the birth for example previously she had a traumatic birth uh traumatic like shoulder dystocia or required instrumental delivery for sex vacuums or previously she had some mental health concern in previous pregnancy or any at any point in her life then make give a proper environment comfortable environment to the woman and the couple as such so review and reassess the plan of care for the pregnancy identify women who need additional care like high risk women they will need additional care or if previous complications are there then they will need additional care at every antenatal contact update the woman's antenatal record it includes details of the history the results of the test perform the examination findings various medicines and discussions so what do we examine we usually measure the height weight and calculate the bmi you do we offer various blood tests to check full blood count blood grouping and anti disease and racist b status so usually height of 140 150 centimeter is average for an indian human approximate weight gain is usually 12 kilograms 2 kg in first 20 weeks and 10 cages in the remaining 20 weeks we give a comfortable environment to the couple to discuss and share information and then offer following training programs so screening for various infectious diseases like hiv syphilis hepatitis training for various blood disorders lexical cell thalassemia and screening for various chromosomal anomalies like uh down syndrome edward for tao and all inform the woman that she can accept or decline at any part of the screening program offered it is her choice to accept or not offer the pregnant woman on ultrasound scan so around at 11 weeks 11 to 14 weeks we do an ultrasound to determine the gestational age detect multiple pregnancy and if the female of the woman ops then we can screen for down syndrome edward syndrome pathos syndrome at around 18 to 20 weeks we screen for fetal anomalies and determine the placental location sometimes placenta is low lying in early weeks but then gradually as the pregnancy advances then the placenta goes up at the antenatal appointment at 28 weeks we do an entity prophylaxis for irish negative women to prevent the future pregnancies a blood test to check full blood count blood group and antibodies if there are any unexpected results from any of the examinations or investigations offer referral according to the local pathways or ensure appropriate information provision and support like if there is a thyroid abnormalities are there hypothyroidism is there it is detected we have to trade that we have to give a toxin if cardiac problem has been observed on examination we because culture and we find that there is some murmur then we can get a 2d echo done and we can get a reference from cardiologist if respiratory problem is there whatever problems are there many women they have teenia or fungal disorders then whatever disorders we investigate and we found it then we can treat accordingly so we have to teach them various physiological changes which are normal in pregnancy you have to tell them about radical we have to ensure that they have fresh air nice sunshine adequate sleep and rest proper diet about daily moderate activities it should not be very less it should not be very more also exercises and relaxation hygiene overall teeth hygiene bladder and bowel sexual counselling is also very important we have to tell them about smoking and hazards of smoking and what hazards it will cause to the baby various medications we have to ask very any other medication any infection history of irradiation and any hazards regarding related to environment travel history and then follow up and minor discomforts and signs of potential complications like if fidelity is there or tyler is there or is there then accordingly we have to investigate and treat so i'll discuss little a few of the common discomforts of pregnancy like urinary frequency excess of uh that increased frequency of urine it is because of uh progesterone so what what we have to do are we we have to tell the female woman that decrease fluid intake at night and maintain fluid intake during day so that there should be no dehydration and void whenever feel urge so the female if it is if she's working then she should be given proper environment proper uh facilities to have washrooms and all to avoid infections so if fatigue is there again adequate rest and asked to go ask to go to bed earlier to have proper sleep rest and decrease again if there is diabetes or increased fluid intake at night then there are chances that the female can the woman can get up in the more at night nasal strappiness is because of estrogen excess which is normal in pregnancy but we have to avoid decongestant because it will though it will temporarily give relief again once the decongestant stop then again there will be more stuffiness so we have to treat symptomatically give humidifiers or normal saline drops dialysm it is an excessive salivation it is again very common in females so we have to ask the female to uh maintain oral hygiene mouthwash can be used chewing gums can be used and again decrease fluid intake at night and maintain the fluid in during day time heartburn or acidity is also very common so we have to ask the female to eat small and frequent meals avoid spicy foods use antacids dependent edema it is also very very common so we have to avoid long standing it is again might be related to occupation some people like traffic police and all they have to stand whole day so we have to try to try to avoid as long as possible and while sleeping they can elevate their legs or while sitting also they can keep the legs at upper position and avoid tight stockings so very cause it is it is also again common in pregnancy to say so we can ask the patient to rest in sims position like this i have to put the picture also she can elevate the legs regularly avoid crossing of legs avoid long standing again because of progesterone maintain regular bowel habits use adequate fluids uh stool softness can be given and topical ointments can be given for pain constipation because of progesterone maintain habits regular bowel habits increase fiber intake in the fluid and she can have more of vegetables and fruits increase fluid intake and some of the iron preparation they are least constipating like iron sucrose etc she can have that iron preparation instead of iron ferrous sulfate so back ache she can uh use former mattress perform some pelvic exercises for leg cramps uh eleventh the legs apply heat muscle heat to the muscles extend uh its affected leg and dorsiflex the foot so faintness or giddiness again it can be related to anemia so we have to evaluate avoid the hot environment as well as very cold environment also so rise slowly from sitting to standing position for a symptomatic bacterial bacterium it should be screened routinely midstream urine should be given and again then the urine should be sent for culture examination also so accordingly we can trade the bacteria identification and treatment of this asymptomatic bacteria it reduces the further risk of pyelonephritis which is again common in pregnancy so for fetal anomalies we can use this combined test to screen for down syndrome and all other chromosomal related abnormalities and women who book late in pregnancies that they can be they can be taken this quadruple test so there are various disorders which we need to screen in antenatal period so mostly gestational diabetes pih and all are there so for gestational diabetes we have to ask the history whether there is a family history if the patient is very obese with the bmi more than 30 kilogram if the previous baby was very big baby like more than 4.5 kgs previous gestational diabetes or family history or usually from south asian countries it is more common in middle east area also compared to uk and us so for hematological conditions uh like sickle cell and thalassemia and it is more common in certain areas like in vidhar region in maharashtra sickle is very common as compared to the western maharashtra so we have to screen accordingly or if any family history is also there then we can check it so it should be enemy screening it is done at booking first then again we have to repeat the cbc at 28 weeks and then near term that is at 36 weeks so if it at any stage anemia is found then we can correct accordingly at near term we have to give blood only if at 28 weeks we can give depending upon the severity of mild moderate and severe anemia we can give ion so parental iron or oral iron if it is mild so normal range if it is 11 gram at first contact and 10.5 or 28 weeks then we have if it is less than that then we have to supplement blood grouping if it is rh negative we have to give ntd at 28 weeks of gestation and post delivery if the baby is positive the baby is negative then there is no need to give entity hepatitis b screening should be offered to pregnant women so that effective post natal intervention can be offered to the infected woman to decrease the risk of mother child transmission also after delivery baby is to be given immunoglobulin as well as vaccine both hepatitis c it is it is not compulsory but we can offer this hepatitis c screening test uh because there isn't sufficient evidence to support its clinical but it is very costly also and there is not much there are no much evidences rubella screening should be offered early in antenatal care to identify the woman at risk and then again we can enable we can vaccinate in post natal period for the protection of future pregnancies since it is a live vaccine it cannot be given during pregnancy nutritional supplements as we all know folic acid we have to start preconception only and then we can continue it till for 12 weeks of gestation it uh the advantage is that it reduces the risk of having a baby with neural tube disorders like an nnk failure spina bifida the recommended dose is 400 micrograms per day and vitamin d the women at greater risk greatest risk are women of south asian african middle eastern family or those women who are covered or they have limited exposure to sunlight or women who are predominantly house bound usually remain indoor so these women are at high risk so we have to supplement women who eat a diet particularly low in vitamin d who consume no oily fish no no fish eggs meat vitamin d fortified margarine or breakfast cereal so these women they would be deficient so we have to supplement women with pre-pregnancy bmi about 330 kilograms per square meter are also at high risk vitamin a in limited doses is to be given excess of if excess if it is given more than 700 micrograms then it might be teratogenic so in limited rows less than that can be given iron supplementation is offered to all the women it has some side effects like unpleasant test constipation so we have to give it along with ascorbic acid so this is all about uh normal routine care so what is changing in past two years one and a half to two years we have seen that various viruses which are not new but uh like virus it has formed a pandemic so this is added new now in antenatal care so we have to screen for these such infections and also various now we knew vaccines are available so we can we will be looking after now this vaccination in pregnancy so in coverage this new delta variant it is associated with more severe disease and there are no reported increase in the congenital anomalies because of over 19 infection vertical transmission is also very rare maternal cova 19 infection is associated with approximately double risk of stillbirth so stillbirth is more as compared to normal pregnant women with no covet virus and it might also be associated with increased incidence of small for gestational babies also there is a risk of freedom but in women with symptomatic over 19 almost two to three times higher than the normal woman with no infection higher rates of perinatal mental health disorders have been reported during the pandemic because of because of anxiety and depression they were in last one and half year i have seen all the female they were very anxious in preconception period also they were very anxious and worried whether they should get pregnant or not what what in what effects this virus will have on the baby also those pregnant female like it is it was seen more in healthcare workers so they were very worried to carry such pregnancy so vaccination it is strongly recommended it should be offered at the same time as the rest of the population based on the age and clinical risk in uk and us it is given in all trimester in india uh we are not recommending it in first trimester and second and third it is given so there is excellent data that about 98 percent of the woman admitted to the hospital and getting severe infection have not so almost 98 percent of the woman are cured and those two percent are having severe infection they never had this vaccine so it is better to take vaccine in pregnancy at any time this is since this uh this is of nice guideline so this modern iron biotech they have given but coefficient vaccine are also given in india so they are also very safe pregnant women receding vaccine shows similar patterns of reporting for the the same adverse effects are there like mild fever headache and all malaise same adverse effects are seen so because of this astrazeneca and jensen vaccine this syndrome is there that is vaccine-induced thrombosis and thrombocytopenia it is an idiosyncratic reaction it is not associated with any of the usual vaccine venous thromboembolism risk factor so there is no evidence that pregnant or postpartum women are at a higher risk of wit that is vaccine induced thrombosis and rhombocytopemia breast feeding can receive that is it is safe in lactation also we need not stop breastfeeding there is no evidence to suggest that covid19 vaccine affects fertility till now there is no evidence and so so that women who are planning pregnancy and fertility treatment can receive cov19 vaccine and do not need to delay the conception this was very common last year that infertile patients they had stopped taking treatment they didn't wanted to continue the treatment or get pregnant last year titanos injection as we all know that titanos injection we give in seven months of pregnancy and then again after one month gap at eight months of pregnancy or one month prior to the expected date of delivery but now recently this tdap has come that that is titanos diphtheria and pertussis it provides the best protection for the mother and infant it is recommended and refer you refer all the patients to receive tdap during pregnancy the optimal timing is between 27 and 36 weeks of gestation preferably during earlier period so that once we give it a 27 or 28 weeks then at least two weeks are required for the maternal antibodies to to be formed so that these by that by that time these antibodies can be transferred to the infant so fever babies will be hospitalized for and die from produces and tdap is given during pregnancy rather than during the post partum period that is instead of giving it to the babies we can give it to the antenatal mother so it is better postpartum kidnap is not optimal it does not provide immunity to the infant who is more if the infants are most vulnerable to this is this serious complications so infantrymen address in in spite of immunization the infant is has the risk of contracting it from siblings grandparents or other caregivers so it takes about two weeks to form these antibodies which means the mother is still at risk for catching and spreading the disease to a newborn baby during this time the pregnant woman should receive tdap anytime during pregnancy if it is indicated for wound care or during pertussis outbreak like during a if an epidemic is there then it can be given at any time if tdap is administered at earlier in pregnancy it should not be repeated between 27 and 36 because it is a single dose so it should not be repeated it should not be offered as a part of routine preconception care so if it is given in antenatal period then during pregnancy we have to give it again protection from pertussis vaccine does not last as long as the vaccine experts would like to so it is recommended to give it during pregnancy to provide optimal protection to the infant if it is administered at a preconception visit it should be administered again during pregnancy between 27 and 36 weeks of gestation so now coming to influenza vaccine it is uh more likely to cause severe illness in pregnant female and postpartum women than in women who are non-pregnant so changes in the immune systems like like we all know that pregnancy is immunocompromised status so the changes in heart and lungs during pregnancy make the pregnant woman more prone for severe illnesses from influenza vaccination has been shown to reduce the risk of flu associated acute respiratory infections in pregnant women by about one half so getting a flu injection can reduce the pregnant woman's risk of being hospitalized with flu by an average about 40 so pregnant women who get a few shots are also helping to protect their babies from flu illnesses for the several months after their birth like at least four to five months when they are too young to get vaccinated it is safe during pregnancy it has if there are a lot of studies where millions of pregnant women were given vaccine and it it should it they should be given injection not the live attenuated or vaccine or nasal spray postpartum women if they breastfeed then also they can receive vaccine the cdc and acip recommend that pregnant women get vaccinated during any trimester of the pregnancy just like covalent so antiviral drugs they can treat flu illnesses and are recommended for pregnant women who are who are sick with flu when used for treatment antiviral drugs can lessen the symptoms and shorten the time your patients are at sick so it will shorten the duration of stay in hospital also and as well as severity also it can previously prevent serious complications like pneumonia like we had uh this pandemic like just like covered in 2009 we had this fine flu pandemic so prompt viral treatment of hospitalized pregnant women was shown to prevent respiratory failures and death in pregnant feelings so studies show that flu antiviral drugs work best for the treatment when they started within two days of getting sick however starting them later can still be beneficial especially for patients who are at higher risk for true complications that is pregnant so again this is very neglected part of the involvement of partner in antenatal care at least in india it is not that better as compared to western countries so women can be supported by their partners during pregnancy they can involve partners according to women's wishes inform the woman that she is welcome to bring a partner to antenatal appointments and classes and we have to consider arranging timing of antenatal classes so that pregnant woman partner can attain if the woman wishes when planning and delivering these anti-natal services ensure that the environment is welcoming for partner as well as pregnant women like for providing information about how partners can be involved in supporting the woman during and after pregnancy like providing information for partners as well as the pregnant woman displaying positive images of partner environment like you know the notice board we can put in the waiting areas we can put some uh booklets or pamphlets can be kept providing seating and consultation rooms for both the woman and her partner consider providing opportunities for the partner to attend appointments remotely as possible so the pole is the partner our husband has any role in antenatal care yes definitely or no we don't think so so how much time we have 20 seconds only yeah it just runs for like 30 seconds it's a very short question so yeah we are getting votes yeah it's fresh in their mind so it's good that you hit the poll right now yes very nice that's good yes people also feel so only one person is there who does not feel that the partner is not important in antenatal care another poll also i think another question also we can put here only for indian partners yes do we have participants from outside india also uh i cannot tell you like right now because we'll have to go back and see from where people are names i saw actually uh that is why i've kept this yeah yeah okay so do you think that indian partners or families as such contribute in antenatal care yes they do or know yes i don't think so 84 percent voted but i don't think so that they contribute this much yeah let it be so i think in all this antenatal care this the key is the communication so there should be proper communication between the woman between the couple as such and the treating gynecologist so when caring for pregnant women we have to listen to her be responsive to her needs and preferences ensure that when offering any assessment intervention or procedure the risk benefits and implications are discussed with the woman and she's aware that she has a right to decline those investigations or interventions woman's decision should be respected even when this is contrary to the waves of healthcare professional so it should be an informed choice so when giving women and their partners information about antenatal care use clear language tailor the timing content and delivery of information to the needs and preferences of the woman and the stage of pregnancy like if the patient has come in the last stage or third prime minister and then that time we cannot tell her the importance of doing chromosomal anomalies or this uh getting a dual scan or anomaly scan that is not the proper time if the patient has come in the first prime minister then we cannot tell her the labor implications or what modes of delivery and also it should be appropriate according to the stage of pregnancy so information should support shared decision making between the woman and her health care team it should be offered on one to one couple basis it can be supplemented by various groups like we can we can have groups of women only or women and partners also then they can discuss it can be supplemented by written information in possible in whatever language according to the local area offered throughout the woman's care individualized and sensitive supportive and respectful it should be evidence based and consistent and if required it can be translated into other languages so we have to explore the knowledge and understanding that the woman and the partner has about each topic to individualize the discussion check that the woman as such the couple understands the information that has been given and how it relates to them because each couple each patient is different so we have to know that their need should be different provide regular opportunities to ask questions and set asides enough time to discuss any concerns so few things are there that we that they might have to they might want to know from you so give them proper time and let them ask them whatever their concerns are and the first antenna so i'll just quickly revise what what we have to do in first first antenatal period at 28 weeks or near term so at first antenatal appointment discuss and give information on about what antenatal care involves and why it is important the the we have to plan the number of antenatal appointments also we have to plan the venue where these end kernel appointments will take place which healthcare professionals will be involved in antenatal appointments how to contact the midwifery like if you are not there then your assistant is there or staff nurses are there or your rms are there how to contact them how to contact the maternity services about urgent concerns like if they receive severe pain or severe bleeding so they should be given all the information screening programs what blood tests ultrasound scan at what time and why they are done everything should be told to them at first time or booking period after that we can tell them how the baby develops during pregnancy so it will create interest in them also what to expect at each stage of stage of pregnancy physical and emotional changes during pregnancy mental health during pregnancy relationship changes during pregnancy because sometimes because the female she is already she is having all this heartburn or epidermis there so she might get irritated and then husband has to at least help her be supportive in whatever changes are there in her body not only physically but also mentally stress is there so there are some changes and changes in relationship which should be told to them in advance so that they will be prepared well prepared for that how the woman and her partner can support each other immunization for flu pertussis and other infections like ovid 19 so infections that can impact on the baby in pregnancy or during birth such as this group group b streptococcus or reducing the risk of infection like encouraging proper hygiene hand washing using sanitizer now using mass continuously or whenever you go outside safe use of medicines health supplements herbal medications if at all they are used during pregnancy then we have to see what herbal medications are being taken resources and support for expectant and new parents should be made available how to get in touch with local and national peer support that should also be if we have some groups then that should be given that if link is there then we can give them online link or if some classes are there then we can recommend those classes for them throughout the pregnancy discuss and give information on physical and emotional changes during pregnancy relationship again during pregnancy how the woman and the partner support each other i think this part is repeated how the parents can bond with their baby and the importance of emotional attachments the result of any blood or screening tests from the previous apartments so we have to always tell them whether we have done if we have done quadruple test and if the result is negative or positive then we have to accordingly tell them what what are the implications of that and after 24 weeks discuss about the babies movement at 28 weeks we can start talking with the woman about her birth preferences and the implications benefits and the risk of different options like now what about and all new these are new ideas coming in we can tell them does these things are there after 28 weeks uh discuss about preparing for labor and work including the information about coping in labor and creating a work plan recognizing active labor we have to tell the woman that she'll have pain there will there be tightness in her abdomen and there will be little bloody and water mixed or whitish discharge from her vagina so we have to tell her whatever are the signs of labor the in postnatal period it includes care of the newborn baby the baby is feeding vitamin k prophylaxis newborn screening postnatal self-care including pelvic exercises awareness of the mood changes and postnatal mental health so there are various antenatal classes like in india we have this garbage and scar classes so we can offer it to nelly paris woman because if this process process of labor is new to them so they don't have at least multiparous woman they had been gone through this procedure so that is they are little bit aware of this so it is more recommended for at least primary gravidas mainly parasol so it includes preparing for labor and birth supporting each other throughout the pregnancy and after work so common treatments in labor and birth how to care for the baby post delivery so it husbands should also be involved how the parents can bond with their baby and the importance of the emotional attachment planning and managing their baby's feeding so it is a shared responsibility of a couple not only of the female so consider antenatal classes for multiparous women if they could benefit from attending for example if they have had a long gap between pregnancies or have never attended antenatal classes before ensure that antenatal classes are welcoming accessible and adopted to meet the need for local communities so these are my references these are the new guidelines published last month only 21st of august 2021 nice guidelines and these are who guidelines all this material was taken from these two guidelines 2016 guidelines my take home message would be that good antenatal care reduces the maternal as well as parent morbidity and mortality so it prepares the pregnant woman and the family for suspected complications with proper care and again at regular antenatal visits that's it thank you so much for your patience if any questions are there then we are in for questions yes hello yeah hello good evening i am a nice presentation i am a consultant neurosurgeon that i was just going through the seminar i found it online i when i looked to the seminar in the antenatal care you find ultrasound abdomen done where you find a lot of fetuses with meningomolocials which are present so what is your concept of the upcoming fetal surgery and your take on the fetal uh spina bifida cases which can be operated for fetal surgery that will i think depend upon the gestational age also yeah if there's a patient goes between the first two hit mutations uh can we take i think we should take up the patient for fetal spina bifida repair intrauterine can be yeah we can take we can take no that i think at mumbai at wadia hospital they are doing already this fetal medicine is there so they are operating such babies you can try your trend you are telling no very advanced yeah it is very advanced uh kind of surgeries i am i'm not doing it i'm not expert in that but it can be done yes the results are somewhat mixed i think that the time will tell but definitely there have been improvements some cases there not been improved in some cases before if we do before the two hit mutation there are chances of improvement and less chiari formation in later stages so ultimately i think it depends upon the means a lot of factors are there like age of the patient if the patient is elderly and conceived out of ivf and all then we'll have to go for this surgery if the patient is young primary gravida in 20s then i think it is not means she have lot of time in her life to conceive again so it depends in general means if the pregnancy is precious one then we can go for the surgery yes because the results are mixed so if by her chance if she gets better than it is surgery isn't still in fluency it has started in france also a lot of surgeries but the point is if we take up before the two-hit mutation it works well for the uterus okay i think it depends upon the age and a lot of other factors also it is in pipeline this surgery nice nice thank you doctor there um so let's take up a few questions from the comments which type of medicines are contraindicated so category x category x medications are contraindicated completely contraindicated in pregnancy thanks for the absolutely amazing presentation thank you bella akash what complications can be avoided in late pregnancy cases as in related to what do you want akash complications and we'll come back to that somebody has asked about water will be twitter water serum af previous uh history of neural tube disorder is there then it is recommended or if elderly woman is there then it is recommended dual markers usually we don't do it comes in dual marker but if a previous history of uh baby with neural tube disorder is there of high or the age of the mother is more then we have to do the oxygen it is safe in pregnancy nice present presentation thank you sheesh rule of parental iron parental line it depends upon the uh at what gestation we detect the anemia if we have lot of time not lot of time but at least if in second trimester we have the patient then we can give parental iron and in some cases this oral line is not absorbed so we can give in that cases not tolerated because some some females they have excess of vomiting or excessive acidity because of parent alliance in such cases we can give because of oral iron sorry in such cases we can give parental line the oxygenate depends we can give it sos also it absolutely depends upon the symptoms what complications are why is water but given so much it is not so much no not it has it it is not that important in india i think in western country it is it is given that importance it doesn't uh and doesn't what is there and doesn't bother water after the baby like aspirations and all no i think i am i don't know about water but but i think because since uh baby is already floating in that laminating fluid it is water only that time baby is not aspirating so the same concept can be applied over there if the baby is delivered and the baby is still not inside that in in the water then there will be no aspiration once the baby is out of the water then then we have to cut the cord then same mechanism for respiration what all exercises can be recommended pelvic exercises we can tell them light pelvic exercises nice presentation shilpa thank you thank you copy of ppt i don't know where can i send the copy of ppt uh we'll actually be summarizing this whole presentation and it'll be available in a pdf format along with the recording of today's session so give us like a couple of days 48 hours and you can come back to the record section and view it there please share your experiences and other where is the question and other statistics of maternal deaths at labor or during surgery status of medical negligence issues so maternal deaths i think most common is pph only and i being in institute we have a good backup of blood bank and all other super specialized facilities so it is less in the institute but i think maternal deaths are more common in peripheral areas because of lack of facilities status of medical negligence i think medical negligence not much because everybody i think we are working more in at least in india looking at the doctor patient relay uh proportion we are working much much more so negligence is not there [Music] thank you please provide me the pdf yeah just know nivea nita told that she will make it available in two days you will inform the new student thank you ashwini in what precaution should be followed in late pregnancy late pregnancy late pregnancy as in and elderly is asking ah gosh thank you do we need to give second dose of tt no no no we don't need to give second dose of tt only tdap single dose women experience cramps or difficulties in moments because of sometimes because of calcium deficiency or we can give carnital also carnature can be given for muscle cramps in pregnancy when we have to give influenza shot at any time any time we went to get an empty scan nt scan between 11.6 weeks to 13.6 what precaution we should take in 20's female who is having three or more miscarriage we can give aspirin 150 milligram od to prevent uh thrombosis thus we can investigate what are the reasons for multiple abortions apply test can be done lasca all this test can be done and this is 75 now it is 150 milligram for anna what is the management of low lying low lying placenta i think low lying so low lying placenta if it is in first early trimester then we have lot of time so that the placenta migrates actually upwards so we need not do anything we have to repeat the ultrasound in third trimester or near term to see whether the placenta is migrated completely or not if it is not then if it is completely low lying placenta then there is no option we have to do scissor in section only like we heard in first pregnancy women in late age women may have complications like miscarriage abnormal babies babies with delayed milestones or neurological complications or could that be avoided with i guess anc yes we can avoid you know for neural tube disorders we can give folic acid antenatally preconceptionally and we can investigate earlier if anything is there like uh doctor they would they only know yes if myelomeningocele is there and since the patient is elderly then that is a precious pregnancy then we can operate such babies in triotrine only that can be prevented at least little bit why cesarean section is common nowadays common nowadays it because of lot of i think because patients also want uh we must have seen uh that all these celebrities they don't want normal deliveries they have electively underwent cesarean sections so even patients it is not just that doctors are doing cesarean section patients are only telling that we don't want to undergo labor even though even we give an option of epidural anesthesia then also they don't want to undergo that procedure of labor polyhydramnios and complications so polyhydramnios the baby will keep on floating between the lycra so there are chances of cord prolapse because of polyhydramnios if the patient goes in labor and the head is not engaged then sudden uh prolapse if the cervix is dilated and started dilating then sudden uh relapse of cord or any other presentation of normal presentation like hand prolapse can occur or foot link any part can get engaged and come out of because of the good uterine activity after once that baby is delivered then such because of polyhydramnios since the uterus is hypertrophic then post delivery there are chances of postpartum hemorrhage in polyhydramnios steroid is given now it is 37 weeks for steroids previously it was 34 weeks now it's 37 weeks good evening ma'am good evening hello hello hi uh ma'am uh i want to ask this question that after how long time uh after a post cesarean section can we perform normal exercises like uh gym and all uh like extensive exercises you want to see yeah yeah extensive physical exertion so it totally depends upon the postpartum period actually and the indication of cesarean section if if it was absolutely normal then by six weeks i think we can start but if some complications were there like endometritis were there or pph was there then i think or if the placenta was low lying in previous caesarean scholars then i think we should give at least six months three months if there's no abnormality during a pregnancy or because of by six weeks i think by 42 days we can start normal heavy exercises yeah yeah yeah okay ma'am thank you at 24 weeks or ga echo suggestive of rv dilation what to do further we can't do anything for uh right ventricular dilatation at 24 weeks and it is just uh it means it is not an indication of termination of pregnancy what we can do that we can get the fetal 2d go again and post delivery only we can do a proper ultrasound and to recover the baby and then manage accordingly dilatation i think it doesn't cause that much problem to the baby and it is usually not solitary it is accompanied with something else some other abnormalities after six weeks which contraception depend again uh if spacing is required then we can advise property for 10 weeks if for a few days only if it is required then oral contraceptive pills are also better co-operation of autumn nothing can be done even if it is cooperation of avatar to the baby you know nothing can be done if i see the positive detected in second trimester what to do next second trimester then we have to do the viral load we have to screen the husband also and then if required then we have to start uh anti retro that retroviral depending upon whatever viral load is there and then same precautions universal precautions during labor and the post delivery we have to give baby then even never happen is it normal to get periods after two months yes yes some some patients get it after one month only before six weeks also some patients start manipulating is anc an option no i don't think that nc is an option at least it should be mandatory compulsory i won't be saying it should be mandatory to improve the maternal and fetal outcome primary patient with five weeks two days with left at nasal cyst of 2.5 centimeter so left at nipple cyst if it is just functional cyst then it is not significant we have to rule out ectopic pregnancy sometimes heterotopic pregnancies can also be there that intrauterine also g psych is there and some cyst is there in that next then it can be an ectopic natural topic but we have to rule out that ring of fire appearance is there hello um my question is if someone has a that tries only 21 babies then how many days from how many days she she can try [Music] she can try means next pregnancy yes next pregnancy she can try in one year means that baby if you have to see what means what is the consequence of that baby and why what mode of what was the mode of delivery and what was the reason but what was the what was the reason for this chromosomal abnormality there is a history of consanguinous marriage then it it will not depend upon the duration of next pregnancy no if it is because of conscientious then it will be there irrespective of the duration even after she conceives after five years or ten years then it is it is going to be their mission is at higher risk so it does not depend upon the duration basically because it is not a neural tube disorder no then we have to replenish the folic acid and all it is chromosomal anomaly it is bound to be there if it is there are high chances that next pregnancy will also be uh having that chromosomal anomaly so it basically does not depend upon the duration or spacing of pregnancy okay so what what what kind of precaution should the they take we have to completely evaluate we have to screen the mother we can screen the father also if such animal is there then we can screen and if we detected early [Music] then we can terminate such pregnancies by 20 weeks and 24 according to the new law uh no no i'm asking if the if they wanted to uh for a next pregnancy then what precautions should they take precautions as such we can just detect it means we cannot uh prevent it because it is a chromosomal animal you know we cannot prevent it so there is as such no precautions can be taken we can just detect it if it is there then we can detect it okay actually i'm working in a community health center so i have a lot of questions in this seminar is actually helping me you know i'm asking repeated questions about the use of aspirin so uh what what actually uh what we can do when we get uh i have many females coming with me with history of recurrent abortions yes you can start once they have conceived now you can start on aspirin 150 previously it was 75 you can start them on aspirin 150 and continue till 36 weeks of the station so we can start from the first trimester itself yesterday we have to start from first time mr only it is most effective in first trimester okay ma'am and uh anything else we like any specific tests we can do uh to uh know the cause of recurrent abortions yes lupus anticoagulant this all this applause can be done lupus anticoagulant cardiolipin test this test can be done okay mom acl and anticardiolipin this test can be right accordingly then you can know the cause right my second question was it was missed actually if we have already given the entity in 28 weeks so we have to repeat it after the delivery in between we have to give it 36 weeks also two doses are recommended 28 weeks and 36 weeks after delivery we will it will depend upon the baby's blood group if the blood group is negative then we need not repeat it if it is positive then we have to give it within seven if we have already given in pregnancy then also we have to repeat it then also we have to give it so it will be like three doses completely three doses yes yes okay ma'am thank you so much thank you welcome so is there a difference in the anc protocol of the pregnancy is ivf as compared to a normally uh normal pregnancy ivf means it is precious pregnancy so we have to screen more visits will also be more and definitely ivf is mean some complications might be there so we usually start aspiring to all ivf patients and we ask them to frequently follow up and extra care definitely it is required in ivf compared to normal pregnancy tablet sustain what what do we want to tablet sustain is to prevent freedom labor can it can be given till 36 weeks sustained it prevents britain labor also progesterones in case of threatened abortion in first trimester gestation such a tablet sustaining threat and abortion now we can continue it 34 weeks it it not only prevents abortion it prevents freedom labor also so we can continue it i think is it normal to have gastric upset yes because of progesterone there is some erosion in the esophagus and the junction of the esophagus stomach so and that sphincter is also relaxed so what happens even if the if you take small meal then also it regurgitates so it is very common in pregnancy thanks a lot ma'am this was a really informative session and i think our audience really enjoyed it and uh they have taken back a lot from this session yeah and i also enjoyed communicating with a lot of miss this platform it was a it was fun kind of thank you i hope we have you soon again uh on a different topic yes and we can ask people only what topic they want sure yeah i mean if y'all have any uh topic ideas that you would like to see from us please do write to us and we can we can keep our topic on covered in pregnancy yeah we could do that yeah thanks again ma'am thank you so much for the session today yeah yeah thank you bye bye bye everyone

BEING ATTENDED BY

Dr. Nilesh Charel & 1201 others

SPEAKERS

dr. Swati Gawai

Dr. Swati Gawai

Assistant Professor Obstetrician , Gynecologist and Endoscopist at LTMMC and Sion Hospital, Mumbai.

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dr. Swati Gawai

Dr. Swati Gawai

Assistant Professor Obstetrician , Gynecolog...

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