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Prenatal care (garbhini paricharya) (view source)
Revision as of 07:01, 15 September 2020
, 07:01, 15 September 2020→Contemporary Approach
==Contemporary Approach==
==Contemporary Approach==
Systematic supervision of a woman during pregnancy is called antenatal care (ANC). Contemporary antenatal care has two main components.
Systematic supervision of a woman during pregnancy is called antenatal care (ANC). Contemporary antenatal care has two main components.
History taking and obstetrical examination:
*Careful history taking and examination (general and obstetrical)
*Advice given to the pregnant woman.
The supervision should be regular and periodic in nature according to the need of the individual.
The aims and objectives of the antenatal care include the screening of high-risk cases, continuing the risk assessment and preventing/detecting the complications at the earliest stage to ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.
World Health Organization’s 2016 recommendations on antenatal care (ANC) for a positive pregnancy experience prioritize person-centered health care, well-being of women and families, and positive perinatal and maternal outcomes.
This model guides pregnant woman about frequency and time of contact for consultation of an obstetrician.
'''Table 3: Antenatal care model by WHO (2016)'''
{| class="wikitable"
|-
|First trimester
|-
|Contact 1 || up to 12 weeks
|-
|Second trimester
|-
|Contact 2 || 20 weeks
|-
|Contact 3 || 26 weeks
|-
|Third trimester
|-
|Contact 4 || 30 weeks
|-
|Contact 5 || 34 weeks
|-
|Contact 6 || 36 weeks
|-
|Contact 7 || 38 weeks
|-
|Contact 8 || 40 weeks
|}
'''History taking and obstetrical examination:'''
Proper personal history, family history, history of present and past illness, medical and surgical history are needed to be taken along with the obstetric and menstrual history.
Proper personal history, family history, history of present and past illness, medical and surgical history are needed to be taken along with the obstetric and menstrual history.
The obstetric history includes status of gravida, parity, number of deliveries (term, pre term), miscarriage, pregnancy termination and living issues.
The obstetric history includes status of gravida, parity, number of deliveries (term, pre term), miscarriage, pregnancy termination and living issues.
In menstrual history, cycle, duration, amount of blood flow, and first day of last normal menstrual period (LNMP) are to be noted.
In menstrual history, cycle, duration, amount of blood flow, and first day of last normal menstrual period (LNMP) are to be noted.
Calculation of the expected date of delivery: This is done according to Naegele’s formula by adding 9 calendar months and 7 days to the first day of LNMP.
'''Calculation of the expected date of delivery:'''
This is done according to Naegele’s formula by adding 9 calendar months and 7 days to the first day of LNMP.
Examination includes general physical examination, systemic examination and obstetrical examination.
===Obstetrical examination===
===Obstetrical examination===
It includes both abdominal and vaginal examination.
It includes both abdominal and vaginal examination.
1. Abdominal examination:
a) Inspection: To note the condition of uterine ovoid, contour of uterus, undue enlargement of uterus, skin condition of abdomen, incisional scar mark on abdomen etc.
'''1. Abdominal examination:'''
b) Palpation: Height of the uterus is measured by placing the ulnar border of the left hand placed on the upper most level of fundus and an approximate duration of pregnancy is ascertained in terms of weeks of gestation. Alternatively, the symphyseal fundal height (SFH) is measured with a measuring tape.
'''a) Inspection:'''
To note the condition of uterine ovoid, contour of uterus, undue enlargement of uterus, skin condition of abdomen, incisional scar mark on abdomen etc.
'''b) Palpation:'''
Height of the uterus is measured by placing the ulnar border of the left hand placed on the upper most level of fundus and an approximate duration of pregnancy is ascertained in terms of weeks of gestation. Alternatively, the symphyseal fundal height (SFH) is measured with a measuring tape.
Obstetrical grips (Leopold maneuvers) are helpful to get an idea about the presentation of foetus, position of different body parts of foetus, attitude, engagement etc.
Obstetrical grips (Leopold maneuvers) are helpful to get an idea about the presentation of foetus, position of different body parts of foetus, attitude, engagement etc.
c) Auscultation: Auscultation of distinct foetal heart sounds (FHS) not only helps in the diagnosis of a live baby, but its location of maximum intensity can resolve doubt about the presentation of the foetus.
2. Vaginal Examination
'''c) Auscultation:'''
Auscultation of distinct foetal heart sounds (FHS) not only helps in the diagnosis of a live baby, but its location of maximum intensity can resolve doubt about the presentation of the foetus.
'''2. Vaginal Examination'''
Strict aseptic precautions should be taken during per vaginal examination during pregnancy. Any history of vaginal bleeding contra indicates the vaginal examination.
Strict aseptic precautions should be taken during per vaginal examination during pregnancy. Any history of vaginal bleeding contra indicates the vaginal examination.
The diagnosis of position and presentation of fetus may be difficult to diagnose accurately by internal examination during pregnancy when the cervix remains closed. Pelvic assessment and test for cephalopelvic disproportion are best done just after the onset of labour or just before the induction of labour.
The diagnosis of position and presentation of fetus may be difficult to diagnose accurately by internal examination during pregnancy when the cervix remains closed. Pelvic assessment and test for cephalopelvic disproportion are best done just after the onset of labour or just before the induction of labour.
During labour, accurate information can be obtained by the palpation of presenting part through the open cervix.
During labour, accurate information can be obtained by the palpation of presenting part through the open cervix.
===Lab investigations===
===Lab investigations===
Blood: Hemoglobin, haematocrit, ABO, Rh grouping, blood glucose and VDRL.
*'''Routine investigations :'''
Urine: Protein, sugar and puss cells.
'''Blood:''' Hemoglobin, haematocrit, ABO, Rh grouping, blood glucose and VDRL.
Serological tests: for rubella, hepatitis B virus and HIV.
Genetic Screening:
'''Urine:''' Protein, sugar and puss cells.
This includes maternal serum alpha-fetoprotein (MSAFP), triple test at 15-18 weeks for mother at risk of carrying a fetus with neural tube defects, down syndrome or another chromosomal anomaly. Non-invasive screening for chromosomal anomaly should be a routine to all pregnant women irrespective of their age.
*'''Special investigations :'''
1st trimester: Presence of an intra uterine gestation sac, and presence of yolk sac or fetal pole within the gestation sac confirms pregnancy.USG is the best method to estimate the gestational age dating. Booking (18-20 weeks) scan is advised for detailed fetal anatomy survey and to detect any structural abnormality including cardiac. It is also helpful in placental localization.
2nd trimester: It is more helpful in assessing the fetal growth using biometric paramrters. The parameters used are biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and Femur length (FL)
'''Serological tests:''' for rubella, hepatitis B virus and HIV.
3rd trimester: All the information of second trimester sonography can be obtained in third trimester. Effective fetal weight, placental maturation, amniotic fluid index etc. are also evaluated.
'''Genetic Screening:'''
This includes maternal serum alpha-fetoprotein (MSAFP), triple test at 15-18 weeks for mother at risk of carrying a fetus with neural tube defects, down syndrome or other chromosomal anomaly. Non-invasive screening for chromosomal anomaly should be a routine to all pregnant women irrespective of their age.
*'''Ultrasound Examinations :'''
'''1st trimester:'''
Presence of an intra uterine gestation sac, and presence of yolk sac or fetal pole within the gestation sac confirms pregnancy.
USG is the best method to estimate the gestational age dating. Booking (18-20 weeks) scan is advised for detailed fetal anatomy survey and to detect any structural abnormality including cardiac. It is also helpful in placental localization.
'''2nd trimester:'''
It is more helpful in assessing the fetal growth using biometric paramrters. The parameters used are biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and Femur length (FL)
'''3rd trimester:'''
All the information of second trimester sonography can be obtained in third trimester. Effective fetal weight, placental maturation, amniotic fluid index etc. are also evaluated.
There are many biophysical tests for prenatal fetal surveillance during late pregnancy which includes ultrasonography, doppler ultra sound velocimetry, cardiotocography(CTG), non-stress test(NSS), fetal biophysical profile(BPP), vibroacoustic stimulation test, contraction stress test (CST)etc.
There are many biophysical tests for prenatal fetal surveillance during late pregnancy which includes ultrasonography, doppler ultra sound velocimetry, cardiotocography(CTG), non-stress test(NSS), fetal biophysical profile(BPP), vibroacoustic stimulation test, contraction stress test (CST)etc.
===Special therapies recommended during pregnancy===
===Special therapies recommended during pregnancy===
===Medicated Enema===
===Medicated Enema===
During the eighth month of pregnancy, evacuative enema (asthapanabasti) is advised for the elimination of retained fecal matter followed by unctuous enema (anuvasanabasti)with oil medicated with madhura group of drugs. [Su Sa. ShariraSthana 3/11]
During the eighth month of pregnancy, evacuative enema (asthapanabasti) is advised for the elimination of retained fecal matter followed by unctuous enema (anuvasanabasti)with oil medicated with madhura group of drugs. [Su Sa. ShariraSthana 3/11]
Acharya Vagbhata advises unctuous enema using ghee processed with madhura group of drugs for cleaning the collected feces and then therapeutic enema(niruhabasti) is given.[A.Hr.ShariraSthana 1/34-35]
Acharya Vagbhata advises unctuous enema using ghee processed with madhura group of drugs for cleaning the collected feces and then therapeutic enema(niruhabasti) is given.[A.Hr.ShariraSthana 1/34-35]
Unctuous enema is continued in ninth month also.
Unctuous enema is continued in ninth month also.
In current practice, the decoction of dashamula herbs and sesame oil processed with same herbs is used for giving evacuative enema after completion of 8th month of gestation. The dashamula group of herbs includes Aegle marmelos(bilwa), Premna Integrifolia/ Clerodendrum phlomidis(agnimantha), Gmelina arborea(gambhari), Oroxylum indicum(shyonaka), Stereospermum suaveolens(patala), Desmodium gangeticum(shalaparni), Uraria picta(prishniparni), Solanum indicum(bruhati), Solanum xanthocarpum(kantakari), Tribulus terrestris(gokshura).
In current practice, the decoction of dashamula herbs and sesame oil processed with same herbs is used for giving evacuative enema after completion of 8th month of gestation. The dashamula group of herbs includes Aegle marmelos(bilwa), Premna Integrifolia/ Clerodendrum phlomidis(agnimantha), Gmelina arborea(gambhari), Oroxylum indicum(shyonaka), Stereospermum suaveolens(patala), Desmodium gangeticum(shalaparni), Uraria picta(prishniparni), Solanum indicum(bruhati), Solanum xanthocarpum(kantakari), Tribulus terrestris(gokshura).
For unctuous enema, oil processed with the above drugs(dashamula) or oil processed with sida cordifolia(bala taila), preparations like dhanwanthara taila , mahanarayana taila , ksheerabala taila etc. are also in practice.
For unctuous enema, oil processed with the above drugs(dashamula) or oil processed with sida cordifolia(bala taila), preparations like dhanwanthara taila , mahanarayana taila , ksheerabala taila etc. are also in practice.
Different practices and protocols regarding enema therapy (basti) are followed. Evacuative and unctuous enema in alternate days for a maximum of 8 days is one protocol. In another protocol, initially, one evacuative enema followed by 3-4 unctuous enema on consecutive days is given. The decision depends upon the physician’s view(yukti) as per the condition and strength of the pregnant lady. In case of severe constipation and if the patient is very weak, initial unctuous enema followed by evacuative enema is effective.
Different practices and protocols regarding enema therapy (basti) are followed.
Evacuative and unctuous enema in alternate days for a maximum of 8 days is one protocol. In another protocol, initially, one evacuative enema followed by 3-4 unctuous enema on consecutive days is given.The decision depends upon the physician’s view(yukti) as per the condition and strength of the pregnant lady. In case of severe constipation and if the patient is very weak, initial unctuous enema followed by evacuative enema is effective.
This kind of enema therapy is useful for facilitating easy delivery. Research works are being conducted on both evacuative enema and unctuous enema as part of prenatal care with an objective of promoting easy delivery.
This kind of enema therapy is useful for facilitating easy delivery. Research works are being conducted on both evacuative enema and unctuous enema as part of prenatal care with an objective of promoting easy delivery.
Two research works were conducted on evacuative enema with 200 ml of decoction of drugs of dashamula added with powder of Adathoda vasica(vasa), Piper longum (pippali and pippalimula), Piper chaba (chavya), Plumbago zeylanica(chitraka), Zingiber officinale(nagara) and Terminalia chebula(haritaki) and mixed with 60 ml of oil processed with dashamula. This enema was given after the completion of 8th month, along with unctuous enema (matra basti) using 60 ml of oil processed with dashamula in alternate days for a duration of 6 days. These studies have reported early engagement of fetal head & timely onset of labour in 90.90% of cases as a result of the abovementioned enema(basti) procedure. ,
Two research works were conducted on evacuative enema with 200 ml of decoction of drugs of dashamula added with powder of Adathoda vasica(vasa), Piper longum (pippali and pippalimula), Piper chaba (chavya), Plumbago zeylanica(chitraka), Zingiber officinale(nagara) and Terminalia chebula(haritaki) and mixed with 60 ml of oil processed with dashamula. This enema was given after the completion of 8th month, along with unctuous enema (matra basti) using 60 ml of oil processed with dashamula in alternate days for a duration of 6 days. These studies have reported early engagement of fetal head & timely onset of labour in 90.90% of cases as a result of the above mentioned enema(basti) procedure.
A single blind comparative study, conducted in 45 primi-gravida and primipara full term pregnancy cases, per rectal administration (matra basti) of castor oil showed better results in the augmentation of labour and shortening the first stage of labour as compared to 2.5 IU of oxytocin in 1 pint of Ringer Lactate fluid administered as per the protocol of induction.
A single blind comparative study, conducted in 45 primi-gravida and primipara full term pregnancy cases, per rectal administration (matra basti) of castor oil showed better results in the augmentation of labour and shortening the first stage of labour as compared to 2.5 IU of oxytocin in 1 pint of Ringer Lactate fluid administered as per the protocol of induction.
===Vaginal Tampon===
===Vaginal Tampon===
During the ninth month, vaginal tampon(yoni pichu) with medicated oil is advised. [ Cha. Sa. ShariraSthana 8/32].
During the ninth month, vaginal tampon(yoni pichu) with medicated oil is advised. [ Cha. Sa. ShariraSthana 8/32].
Oil processed with sida cordifolia(bala taila), formulations like dhanwanthra taila are in current practice for vaginal tampon during ninth month of pregnancy.
Oil processed with sida cordifolia(bala taila), formulations like dhanwanthra taila are in current practice for vaginal tampon during ninth month of pregnancy.
Filling of vagina(yoni poorana) with castor oil(erannda taila) with the same oil is beneficial in promoting the onset and progression of normal labour.
Filling of vagina(yoni poorana) with castor oil(erannda taila) with the same oil is beneficial in promoting the onset and progression of normal labour.
===Medicated water for bath===
===Medicated water for bath===
The cold decoction of pulp of Aegle marmelos(bilva), Gossipiumherbaceum(karpasa), petals of rose(patali),pounded leaves of Azadirachtaindica (pichumanda), Clerodendrumphlomidis(agnimantha),Nardostachysjatamansi(jatamamsi), and Ricinus communis (eranda) or water prepared with all fragrant drugs(sarvagandhodaka) should be used for bathing by the pregnant woman.[A.S. Sharira Sthana 3/14] Cold decoction of pounded leaves of drugs capable of suppressing [[vata]] is generally advised. [A.Hr.ShariraSthana 1/68]
Commonly used medicines for promotion of health of mother and fetus:
The cold decoction of pulp of Aegle marmelos(bilva), Gossipiumherbaceum(karpasa), petals of rose(patali),pounded leaves of Azadirachta indica (pichumanda), Clerodendrum phlomidis(agnimantha),Nardostachys jatamansi(jatamamsi), and Ricinus communis (eranda) or water prepared with all fragrant drugs(sarvagandhodaka) should be used for bathing by the pregnant woman.[A.S. Sharira Sthana 3/14] Cold decoction of pounded leaves of drugs capable of suppressing [[vata]] is generally advised. [A.Hr.ShariraSthana 1/68]
==='''Commonly used medicines for promotion of health of mother and fetus:'''===
Some herbal formulations are mentioned as preventive medicines for habitual abortions in particular months. These are prescribed in general also for promoting the proper growth and development of the fetus. Powder or paste of the drugs can be used along with milk. Now a days, these are available in tablet/capsule form also.
Some herbal formulations are mentioned as preventive medicines for habitual abortions in particular months. These are prescribed in general also for promoting the proper growth and development of the fetus. Powder or paste of the drugs can be used along with milk. Now a days, these are available in tablet/capsule form also.
Month Drugs*
{| class="wikitable"
1st month Madhuca longifolia(madhuka), seeds of Tectona grandis (sakabeeja), Pueraria tuberosa. (Willd.) DC. (payasya), Cedrus deodara (devadaru)
|-
2nd month Ficus rumphii Blume (ashmantaka), Sesamum indicum (black tila), Rubia cordifolia (tamravalli), Asparagus recemosus(shatavari)
!Month !! Drugs*
3rd month Dendrophthoe falcata (Vrukshadani), Pueraria tuberosa. (Willd.) DC.(payasya), Callicarpa macrophylla Yahl. (priyangu), Nymphaea alba Linn (utpala), Hemidesmus indicus (shariba)
|-
4th month Cynodon dactylon (durva), Hemidesmus indicus (shariba), Pluchea lanceolata Oliver & Hiern (rasna), Clerodendrum Serratum (bharangi), Glycyrrhiza glabra Linn. (yastimadhu)
|1st month || Madhuca longifolia(madhuka), seeds of Tectona grandis (sakabeeja), Pueraria tuberosa. (Willd.) DC. (payasya), Cedrus deodara (devadaru)
5th month Solanum Indicum Linn. (bruhati) , Solanum Xanthocarpum (kantakari), Gmelina arborea (kasmari), stem bark and leaf buds of latex yielding trees,ghee
|-
6th month Uraria picta (prishniparni), Sida cordifolia (bala), Acorus Calamus Herb (vacha), Moringa oleifera (shigru), Tribulus terrestris (shwadamshtra), Glycyrrhiza glabra Linn. (madhuparnika)
|2nd month || Ficus rumphii Blume (ashmantaka), Sesamum indicum (black tila), Rubia cordifolia (tamravalli), Asparagus recemosus(shatavari)
7th month Trapa bispinosa Roxb. (Shringaaka), Nelumbo nucifera Gaertn(bias), Vitis vinifera (draksha), Scirpus grossus Linn. (kaseru), Madhuca longifolia(madhuka),sugar
|-
8th month Feronia linonia (Linn.)(kapitha), Aegle marmelos L.(bilwa), Solanum Indicum Linn. (brihati), Trichosanthes Dioica.(patola), Saccharum Officinarum Linn. (ikshu), Solanum xanthocarpum(nidigdhika).
|3rd month|| Dendrophthoe falcata (Vrukshadani), Pueraria tuberosa. (Willd.) DC.(payasya), Callicarpa macrophylla Yahl. (priyangu), Nymphaea alba Linn (utpala), Hemidesmus indicus (shariba)
9th month Hemidesmus indicus (shariba), Pueraria tuberosa. (Willd.) DC.(payasya), Glycyrrhiza glabra Linn. (madhuyashti)
|-
|4th month || Cynodon dactylon (durva), Hemidesmus indicus (shariba), Pluchea lanceolata Oliver & Hiern (rasna), Clerodendrum Serratum (bharangi), Glycyrrhiza glabra Linn. (yastimadhu)
|-
|5th month || Solanum Indicum Linn. (bruhati) , Solanum Xanthocarpum (kantakari), Gmelina arborea (kasmari), stem bark and leaf buds of latex yielding trees,ghee
|-
|6th month || Uraria picta (prishniparni), Sida cordifolia (bala), Acorus Calamus Herb (vacha), Moringa oleifera (shigru), Tribulus terrestris (shwadamshtra), Glycyrrhiza glabra Linn. (madhuparnika)
|-
|7th month || Trapa bispinosa Roxb. (Shringaaka), Nelumbo nucifera Gaertn(bias), Vitis vinifera (draksha), Scirpus grossus Linn. (kaseru), Madhuca longifolia(madhuka),sugar
|-
|8th month || Feronia linonia (Linn.)(kapitha), Aegle marmelos L.(bilwa), Solanum Indicum Linn. (brihati), Trichosanthes Dioica.(patola), Saccharum Officinarum Linn. (ikshu), Solanum xanthocarpum(nidigdhika).
|-
|9th month || Hemidesmus indicus (shariba), Pueraria tuberosa. (Willd.) DC.(payasya), Glycyrrhiza glabra Linn. (madhuyashti)
10th month Zingiber officinale(Shundhi)+ Pueraria tuberosa. (Willd.) DC.(payasya)/ Zingiber officinale (shundhi)+ Glycyrrhiza glabra Linn (madhuyashti)+ Cedrus deodara devadaru/ only Pueraria tuberosa. (Willd.) DC.(payasya)
10th month Zingiber officinale(Shundhi)+ Pueraria tuberosa. (Willd.) DC.(payasya)/ Zingiber officinale (shundhi)+ Glycyrrhiza glabra Linn (madhuyashti)+ Cedrus deodara devadaru/ only Pueraria tuberosa. (Willd.) DC.(payasya)
|}
*[ Su Sa Sharira Sthana 10/ 58-65]
*[ Su Sa Sharira Sthana 10/ 58-65]
Some single drugs in the form of milk decoction (ksheera kashaya)in each month of pregnancy are widely prescribed by Ayurveda practitioners, mainly in southern part of India.
Some single drugs in the form of milk decoction (ksheera kashaya)in each month of pregnancy are widely prescribed by Ayurveda practitioners, mainly in southern part of India.
Month Drug
{| class="wikitable"
1st month Sida cordfolia(bala)
|-
2nd month Ipomea sepiaria(lakshmana)
!Month !! Drug
3rd month Solanum Indicum Linn. (bruhati) and Solanum xanthocarpum (kantakari)
|-
4th month Desmodium gangeticum(shalaparni)
|1st month || Sida cordfolia(bala)
5th month Tinospora cordifolia(guduchi)
|-
6th month Solanum xanthocarpum (kantakari)
|2nd month || Ipomea sepiaria(lakshmana)
7th month Hordeum vulgare(yavaka)
|-
8th month Marsedenia tenacissima (morata)
|3rd month || Solanum Indicum Linn. (bruhati) and Solanum xanthocarpum (kantakari)
9th month Asparagus racemosus(shatavari)
|-
|4th month || Desmodium gangeticum(shalaparni)
|-
|5th month || Tinospora cordifolia(guduchi)
|-
|6th month || Solanum xanthocarpum (kantakari)
|-
|7th month || Hordeum vulgare(yavaka)
|-
|8th month|| Marsedenia tenacissima (morata)
|-
|9th month || Asparagus racemosus(shatavari)
|}
===Therapeutic measures to be avoided===
===Therapeutic measures to be avoided===
*Excessive nourishment(santarpana) and excessive emaciation(apatarpana) [Su.Sa.ShariraSthana 10/3]
*Untimely use of oleation(snehana) [Su.Sa.ShariraSthana 10/3]
*Blood-letting[Su.Sa.ShariraSthana 10/3]
*Repeated excessive massage with oil and unguents. [Su.Sa. Sharira Sthana 10/3]
*All types of cleansing therapies like [[Panchakarma]](shodhana procedures) [A.Hr.ShariraSthana 1/44]
*Sudation(swedana) and cauterization with alkali(Kshara karma)[Y.R. Ksheeradosha Chikitsa]
==General guide Lines for treatment of diseases during pregnancy==
==General guide Lines for treatment of diseases during pregnancy==
• The diseases of pregnant woman should be treated with use of soft(mrudu), sweet(madhura), cold(sheeta), pleasing and gentle drugs, dietetics and behavior. [Cha. Sa. Sharira Sthana 8/22]
• The diseases of pregnant woman should be treated with use of soft(mrudu), sweet(madhura), cold(sheeta), pleasing and gentle drugs, dietetics and behavior. [Cha. Sa. Sharira Sthana 8/22]