On the Brink of Birth

A full term fetus, is shown in its mother’s womb in this Leonardo da vinci drawing. One of the first accurate renderings of a part of the human anatomy. The smaller sketches depict details of the uterus. Of all the triumphs of the body, its crowning glory is the power to reproduce its kind and pass some of its hereditary characteristics on to later generations.

We have come a long way from

‘Stand By’ the pregnant woman

Support Normal Delivery

Prevent Abnormal Delivery

Predict onset of Adverse Effects

Obstetrics in Broad Perspective

Structure of reproductive organs

Giving birth to another life is reproduction.

Human reproduction is unique.

Organs Concerned with Reproduction

Male & Female

External Genital Organs

Internal Genital Organs

External Genital Organs Female

are referred to collectively as the vulva.

• Labia Majora - Mons Pubis • Labia Minora • Clitoris • Vestibule / Bartholin's glands

Internal Genital Organs Female

• A pair of Ovaries - the primary reproductive organs

• A pair of Fallopian Tubes - uterine tubes

• The Uterus - body & cervix

• The Vagina - receives male sperm

Ovaries

Female sex cells and sex hormones

Follicles

400,000 primordial follicles at puberty. Preovulatory or graafian follicle

Fallopian Tubes

Uterine tubes

The ovary has 3 functions

1. The production of ova

2. The production of estrogens

3. The production of progesterone}Control of menstruation

The gonadotrophic hormones of the anterior pituitary control the production of hormones by the ovary itself.

Follicle stimulating hormone [FSH] is essential for the early development of the Graafian follicle; and the pituitary also controls this growth by the luteinizing hormone [LH] and the secretion of the corpus luteum.

Estrogens are secreted by the ovary from childhood until after the menopause.

They are described as follicular hormones as they are constantly produced by numerous ovarian follicles and like all hormones circulate in the blood stream.

They provide for the development of the female sex organs and for the secondary sex characteristics which bring about the changes in a girl at puberty.

Progesterone is secreted by the corpus luteum. It continues the work begun by the estrogens on

the endometrium and causes it to become thick, soft, and velvety, ready for the reception of a fertilized ovum.

Progesterone inhibits menstruation.

Uterine Support

Transverse cervical & Uterosacral LigamentsSpokes of a bicycle wheelLavator aniStructures passing throughRectum, urethra and uterine cervixControls urinary continence & defecation

Three layers of uterus

The endometrium

The myometrium &

The perimetrium

Vagina

that receives the male sperm during intercourse

9 Cm long

Ovulation

mature oocyte is released from the primordial follicle.

once a month.

Reproductive cycle

menstrual bleeding

ovum travels through the fallopian tube to the uterus

Structure of male reproductive organs

Testes

suspended inside a sac called the scrotum by a spermatic cord

Functions of the Testes

produce sperm cells and secrete male sex hormones

Internal Organsmale

• Epididymis – within the testis• Vas deferens – tube• Ejaculatory ducts – open into the prostatic urethra• Seminal vesicle – two pouches that are attached to

the vas deferens • Urethra – transport sperm through the penis • Prostate gland – secretes an alkaline fluid to keep

the sperm mobile • Bulbourethral glands – release a mucous-like fluid• Semen – sperms and secretions

A Seed is Born The male reproductive system manufactures and transports the tiny sperm cells of human seeds. Formed in the testes in astronomical numbers, sperm cells are stored in the epididymis and travel, suspended in secretions from the seminal vesicle, prostate and Cowper’s gland, along the deferent duct into the urethra that leads through the penis.

The testes are the male organs of generation where spermatozoa are formed and the male sex hormone, testosterone is produced.

The testes develop in the abdominal cavity during fetal life, and descend through the right and left inguinal canals into the scrotum towards the end of the pregnancy.

There they lie obliquely suspended by the spermatic cords.

Testosterone, is secreted by the interstitial cells, which lie in the interspaces between the seminiferous tubules of the testis under the stimulation of the luteinizing hormone (LH) of the pituitary.

The secretion of testosterone increases markedly at puberty and is responsible for the development of the secondary sexual characteristics; growth of the beard; deepening of the voice; enlargement of the genitalia.

Male Bony Pelvis Female Bony Pelvis

DIFFERENCE BETWEEN MALE AND FEMALE PELVIS

Female Pelvis with Fascia and Ligaments

Fertilization & Implantation

The male reproductive system manufactures and transports the tiny sperm cells of human seeds.

Formed in the testes in astronomical numbers, the sperm cells are stored in the epididymis and travel, suspended in secretions from the seminal vesicle, prostate and Cowper’s glands, along the deferent duct into the urethra that leads through the penis to fertilize the ovum.

Fertilization

One Seed + One Egg

The next stage of development, from month 2 until birth, is the fetal period of development.

Life begins when an egg, previously released from one of the two ovaries, merges with just one of the hundreds of millions of sperm cells supplied through the vagina by the male reproductive system. The fertilized egg then descends to the wall of the uterus, where it implants itself to begin gestation.

Attachment of the zygote to the wall of the uterus

Fetal life support systems

– Placenta– Membranes– Umbilical Cord

Placenta

The placenta is where the blood vessels of the mother and the embryo intertwine but do not join, to facilitate the exchange of oxygen, nutrients, and waste materials between the mother and the embryo. In the placenta, embryonic/fetal blood flows into thousands of tiny projections (villi), where exchanges occur between the mother and embryo/fetus. The placenta covers about a quarter of the uterine surface, thus providing a large surface area for such exchange. By the 18th to 20th week of pregnancy, the placenta is fully formed, and is about 450gms (1lb) by birth.

AmnionMembranous sac which surrounds & protects the embryo.

umbilical cordLifeline between the fetus and the placenta in the uterus

Later stage in the development of the umbilical cord

Fetus of about eight weeks, enclosed in the amnion.

Formation and structure of the umbilical cord – By the end of the third week of development the embryo is attached to placenta via a connecting stalk

Beginning of the umbilical cord

Development of the umbilical cord

Development of the yolk sac & the duct

Cross section of normal umbilical cord

Fetus at ~53 days

Umbilical cord protects the fetal vessels that connect the placenta & fetusFetus and placenta from a 17 week gestation

Embryo

Embryonic period of development (2 to 8 weeks post-conception), where the zygote is now referred to as the embryo.

As the zygote implants and becomes the embryo, the blastocyst begins to form 2 layers:

• The inner layer of cells is called the endoderm and eventually develops into the digestive and respiratory systems.

• The outer layer is divided into 2 parts: the ectoderm (outermost layer of cells) and mesoderm (middle layer; between the endoderm and ectoderm). The ectoderm will develop into the nervous system, sensory receptors (eyes, ears, nose, etc.) and skin (including nails and hair), while the mesoderm will become the bones, muscles, excretory, circulatory and reproductive systems.

Embryo to Fetus

Medical science has discovered a good deal about the day to-day development of the human embryo, its growth into a fetus and its ultimate birth as a child. At about six or seven days after conception the new organism embeds itself in the lining of the uterus. At this stage it is called an embryo until the seventh week. After that the organism is called a fetus until the time of its birth.

fifteen days twenty-one days thirty days thirty-four days six wks eight wks

The limbs appear as tiny buds on the embryo when it is less than a month old. At that time, the embryo is completely formed, although it is less than half an inch in length. The heart is usually beating a few days before the end of the first month of life. At this time the baby is enclosed in a sort of bag called the amniotic sac, in a completely liquid environment. He will remain in the sac until it breaks at birth, or a little before, exposing the child to the external environment.

By the seventh week, the embryo is recognizably human. The brain has formed sufficiently to send out electrical impulses and even at this early stage the brain is the coordinator of the other organs. Growth is very rapid. The embryo grows at the rate of about a millimeter a day. The skeleton begins to develop when the embryo is forty-six to forty-eight days old.

The fetus can move and be quite active during the third month and certainly is so from the time it develops muscles and can move its limbs and soon learns to grasp. The muscular contractions, which will later become facial expressions, can be recorded. In most cases, the mother does not feel the movement of her child until it has grown sufficiently and the uterus has expanded above the natural container of the pelvis, usually the fourth or fifth month.

The nervous system is also developing – the fetus can react to pressure and loud noise. This sensitivity to outside stimulus is perhaps the most important thing about the fetus.

The fetus makes swallowing movements as early as the 14th week of gestation. By 26 to 28wks it actively sucks and tastes to gain nourishment. Neurological activity manifests by about 8wks. By 14wks, mother can feel the movement of the fetus. At 22wks, the fetus has a weak phonation (voice). Acceleration of the fetal pulse in response to noise is noticed by 25th week. There is evidence that fetal activity may be responsive to maternal emotions, as a result of placental transfer of epinephrine and other hormones.

It is believed that the first part of the human body to become sensitive is the mouth. Only later do the eyes, hands and other body parts achieve sufficient nerve ending to be sensitive to touch. By the end of the ninth week of fetal life the only important parts of the body, which are not sensitive to touch, are the back and the top of the head, which will remain insensitive until after birth.

By the end of the fourth month of life, the baby has gained half the height he will reach before birth. Certainly during the fifth month the mother can detect his movements. He sleeps and wakes, and has already acquired some of his favorite physical positions.

During the sixth month, the child begins to accumulate some fat and he gets the buds for his permanent teeth behind the milk teeth that are now developing. By the end of the sixth month the child is as much as a foot long and weighs about half a kilo Fingernails have started to grow and he is very active.

The last three months of life, the III Trimester in the womb see the completion of many body parts, but this is mostly just polishing off. During this final period the child is primarily growing, gaining weight and achieving muscular control. By the time he is ready to be born he is so big that his movements are extremely hampered by the restricted area now provided by the uterus. His demands are such that the placenta is no longer able to fulfill them all.

This spectacular growth occurs in the mother’s own body with no conscious effort on her part. With the help of various yoga practices, however, the expectant mother can become more aware of the fetus in the womb, fully experiencing this most intimate relationships.

The average weight of the Indian baby at 40 weeks of pregnancy is 2,750Gms at birth.

Physiology of Pregnancy

Functional and structural alterations develop in the entire body during the course of pregnancy and delivery.

Early changes are due, in part, to the energy demands brought on by the fetus, placenta and uterus and, in part, to the increasing levels of pregnancy hormones, particularly those of progesterone and oestrogen.

Later changes, starting in mid-pregnancy, are anatomical in nature and are caused by mechanical pressure from the expanding uterus.

changes in the cardiovascular system

Pregnancy-induced changes in the cardiovascular system develop primarily to meet the increased metabolic demands of the mother and fetus. Despite the increased workload of the heart during gestation and labour, the healthy woman has no impairment of cardiac reserve.

Renal systemUndergoes tremendous anatomic and physiologic changes during pregnancy. With advancing gestation, the enlarging uterus can compress the ureters as they cross the pelvic brim and cause further dilatation by obstructing the flow of urine. These changes may contribute to the frequency of urinary tract infections during pregnancy.

Respiratory System

Hormonal changes may cause swelling of the lining in the nose, oropharynx, larynx, and trachea. Symptoms of nasal congestion, voice change and upper respiratory tract infection may prevail throughout gestation.

  Oxygen consumption increases gradually in response to the needs of the growing fetus, culminating in a rise of at least 20% at term. During labour, oxygen consumption is further increased (up to and over 60%) as a result of the exaggerated cardiac and respiratory workload.

Gastrointestinal System

The enlarging uterus causes a gradual displacement of stomach and intestines and may cause esophageal reflux resulting in mild vomiting.

Typical skin changes are

1.       Melasma or "mask of pregnancy"

2.       Urticaria of Pregnancy

Skin

Metabolism

As the fetus and placenta grow and place increasing demands on the mother, phenomenal alterations in metabolism occur.

The most obvious physical changes are weight gain and altered body shape.

Weight gain is due not only to the uterus and its contents but also to the increase in breast tissue, blood and water volume in the form of extra vascular and extra cellular fluid.

Deposition of fat and protein and increased cellular water are added to the maternal stores.

The average weight gain during pregnancy is 12.5Kg.

Hormonal Changes

Hormones are chemically diverse substances (e.g. steroids; peptides), which are released into the bloodstream in response to some stimulus, and activate cells. The main hormones are

 

Human Chorionic Gonadotropin (hCG)

Oestrogen  

Progesterone

Prolactin  

Relaxin

Oxytocin

Prostaglandin

Uterus, Cervix and Breasts

The anatomical, physiological and biochemical adaptations that take place in women during the short span of human pregnancy are profound.

Three Trimesters & Labour

Why is pregnancy period divided into Three Trimesters?

Out of the nine months of pregnancy the First three months (1st Trimester) is a period of organ differentiation in the fetus.

The Second three months (2nd Trimester) is the completion of the various organs and systems in the fetus.

The Third three months (3rd Trimester) is the final growth period of the fetus. There are various changes in the mother at each trimester.

First Trimester

1. First Trimester

1. Amenorrhoea

2. Morning sickness

3. Frequency of micturition

4. Breast discomfort

5. Fatigue

6. Vaginal signs

7. Cervical signs

8. Uterine Signs

Second & Third Trimesters & Labour

2. Second Trimester1. Symptoms 2. Signs 3. Abdominal examination 4. Palpation 5. Auscultation

3. Last Trimester 1. Symptoms 2. Signs

4. Labour 1. First stage of labour 2. Second stage of labour 3. Third stage of labour

New Born

A healthy new born cries vigorously as soon as he is born, kicking his limbs actively, giving the greatest joy to the tired mother.

Prenatal Care Startling new research suggests that adult illnesses like Diabetes, obesity, asthma, hyper tension, etc., may have their roots before birth; it may be termed as ‘Gestational Conditioning’. Now ‘Fetal programming’ is a new paradigm in public health.

Aims of Antenatal Care

(1) The screening and prevention of maternal or fetal problems,

(2) Management of maternal or fetal problems, and

(3) The preparation of the couple for childbirth and childrearing.

Investigations – Sonography – Ultrasound & Doppler

(1) Detects the movement of red blood cells

(2) Altered measurements of blood flow within maternal and fetal vessels

Doppler Waves

Diet in pregnancy The pregnant woman is nourishing a dynamic life within her. Hence she should eat a balanced diet including all the nutrients like carbohydrates, proteins, fats, minerals, vitamins, micronutrients and anti-oxidants. If she was taking 60 to 80 grams of proteins before, now she must take 100 grams of protein, if she was taking 60 to 80 grams of fat before, now she must take 100 grams of fat, similarly if she was taking 2500 calories daily she must now take 2800 – 3000 calories per day. Hence she needs more fat, more carbohydrates, more protein, and more minerals & vitamins. She has to store energy to bear the pain and effort and strength needed during delivery. She must be prepared to feed her baby as soon as the child is born. Her milk must be rich to provide a complete food to the baby till the age of 4months. The baby draws all the required nutrition from the mother, through her breast milk without any hesitation whether the mother is getting enough to eat or not.

This will make the mother weak if she doesn’t take adequate balanced diet. It is equally important that she should not over eat and become obese. Obesity in pregnancy due to excessive intake of rich food without enough physical activity to spend that energy, can lead to many complications during pregnancy and delivery.

Four Groups of Food

1. Proteins = 4 Kilo calories/GramAll Dhals – Bengal gram, Green gram, Peas Soya, Horse gram, etc.,Green vegetables including Palak, etc.,Milk products like cheese, curds, buttermilk, ghee, butterMeat, egg, fish

2. Fat = 9 Kilo calories/GramOil, Butter, Ghee, Oily Seeds

3. Carbohydrates = 4 Kilo calories/GramRice, Wheat, Corn, Ragi, etc.,Fruits, VegetablesPotato, Sweet Potato, Root VegetablesJaggery, Sugar, Honey, Milk

4. Micronutrients & Antioxidants = Minute QtyCalcium, Iron, Iodine, Copper, Cobalt, Sodium, Phosphorous, Potassium, etc.Vitamins-ABCDEK, etc.,Antioxidants like Garlic, Turmeric, Ginger

For a balanced, healthy diet, all the following are essential in a certain proportion. Eating just carbohydrates, or just proteins to fill her stomach is not an ideal thing to do. It does not give proper nutrition neither to the mother nor to the growing fetus.

 Hence, The pregnant woman must plan her diet and use different food items containing all the essential foods. Vitamins, minerals and antioxidants although in minute quantities are necessary to ward off infections that keeps the mother and the fetus healthy.

 She also needs more calcium for her bones and teeth. If the pelvic bones become soft without calcium it leads to osteomalacia and causes severe difficulty during labour. Burkha women (Those who cover their body with thick black cloth) suffer from this disease and the child born to her will also have calcium and vitamin D deficiencies leading to skeletal deformities.

  The mother-to-be should eat healthy, natural foods- preferably untreated- and avoid food, which is overcooked or containing too much fat, sugar or seasoning.

Three groups of essential food substances in pregnancy1.Supply energy to the mother and the fetus2.Help in building and repairing tissues and organs3.Protect the mother against infection and disease, help in the proper functioning of all the systems including that of the fetus.

These food substances should be pleasing and acceptable PsychologicallyPhysiologically andSocially

Misconceptions and false beliefs about diet in pregnancy.

1. Ignorance

2. Poverty and

3. Unscientific customs are the main causes for these beliefs.

They blame almost all food items regarding fruits. The old belief is that banana and orange causes abortion and also respiratory problems. There is absolutely no truth in this. In fact there is lot of vitamin A, C and iron in these fruits, which are very essential to the pregnant woman.

Regarding tender-coconut water and other common fluids, the misconception is that it causes cold, cough, fever and is harmful to the growing child. This again is not true, They contain lot of minerals and vitamins and help in preventing urinary infection which is common in pregnancy.

  Regarding dhals, they think that they cause arthritis and gas formation which may affect the baby. These is also not true. In fact they contain abundant proteins which supply energy to the pregnant woman.

Regarding vegetables, the wrong concept is that brinjal and green vegetables cause diarrhoea, allergy and green skin marks. This understanding is also not true. They contain abundant vitamin A, proteins and iron which help in constipation that is common in pregnancy.

What does yoga recommend as a good diet for preventing problems in pregnancy?

According to yoga ‘moderation’ is the key – Yoga lays emphasis on the effect of food and diet on mind. Accordingly all foods have been classified into three major types i.e., Satwic, Rajasic and Tamasic foods.

Yogic Concept of Balanced DietThose Diets which restore balance at all levels        Physical        Pranic        Mental & Emotional        Intellectual

Satvic foodVitality h PurityStrength h CheerfulnessHealth h Happiness Substantial h Good appetiteStamina h Likable

Rajasik foodBitter h SourSaline h Steaming hotPungent h DryBurning

Tamasik foodOld foodDevoid of taste Foul smelling StaleLeft over Impure Food

1. Plan menu taking into consideration appearance, texture, flavor and overall acceptability.

2. Calories upto 55 to 66 percent to be provided through complex carbohydrates.

3. Sprouted grams and malted cereals included to improve digestibility and protein quality.

4. Foods prepared preferably by pressure cooking or streaming or boiling or mild baking to retain nutrients and break monotony.

Combining the knowledge from the west and the east, it means that, the best type of diet for a pregnant woman is a Satvic, simple wholesome vegetarian diet. The ingredients could include all (less polished) cereals and lentils, plenty of vegetables (cooked and raw), fruits, butter milk instead of curd or milk, moderate quantity of oils and not solid fats, plenty of water and malted drinks; replace coffee and tea by herbal tea; avoid stored and tinned foods, aerated drinks, foods with preservatives and colouring agents; select grains and vegetables grown organically.

Quantity of the items are to be calculated according to the, state of the mind, body weight, the level of physical activity, and the degree of weight gain as the pregnancy advances.

Obtaining carbohydrates from unprocessed sources like nuts, fruits and whole-grain breads is healthier than the alternative for pregnant women. Don’t eat just before or while you’re exercising, though. The ideal eating pattern is 2 to 3 hours before yoga exercises and immediately afterwards.

Diet to be taken in the 1st trimester of pregnancy

Along with the normal food containing proteins, fat and carbohydrates, she must take plenty of fluids such as fruit juices, lime juice, orange juice, tomato juice, thin butter milk and tender-coconut water, as per the calorie requirements.

Diet in the 2nd and the 3rd trimesters

Because of the gradual increase in the pressure on the chest by the gravid uterus she should take frequent small feeds which are easily digested and should avoid very hot spicy or excessively salty preparation.

Perinatal problems

High Risk Pregnancy [HRP]

Maternal & Fetal

Low Birth Weight [LBW]

Although LBW is defined as BW less than 2500g, for practical purposes the really significant risks of the problems are confined mainly to premature babies of less than 33 weeks gestation, and extremely small for gestational age (SGA babies), that is, those with birth weights below the third percentile.

Incidence of LBW – 5% to 40% of live births.

Pre-Term Labour [PTL]born before 37 completed weeks of gestation Incidence of PTL – 20-25%. (a) Maternal (b) Placental (c) Fetal (d) Idiopatic

Intra Uterine Growth Retardation [IUGR]True IUGR represents a major risk factor to the fetus and a dilemma for the obstetrician. Appropriate management involves making a diagnosis of IUGR, defining the underlying aetiology, accurately assessing the fetus and placenta and subsequently planning the most appropriate form of surveillance and delivery.

Hypertension Arising in Pregnancy [PIH]Incidence – 5-15%

Gestational Diabetes Mellitus [GDM]

Stress and its adverse effects on pregnancy

1. Physical Stresses 2.  Psychological stresses

Perinatal problems due to stress 1. Spontaneous abortion 2. Pre-eclampsia3. Structural malformations 4. Preterm delivery5. Low Birth weight

Transmission of maternal stress to the unborn baby 1. Reduction in blood flow to the uterus and fetus at

increased levels of maternal stress; 2. Transplacental transport of maternal hormones; 3. Stress-induced release of placental CRH to the

intrauterine environment