1. 1. Principles and Practice of Obstetrics and Gynecology for Postgraduates Federation of Obstetric and Gynaecological Societies of India
2. 2. Disclaimer The statements and opinions contained in the chapters of the book on Principles and Practice of Obstetrics and Gynecology for Postgraduates are solely those of the individual authors and contributors, and do not necessarily reflect the opinions or recommendations of the FOGSI. Because of rapid advances in the Medical Sciences, the editors recommended that independent verification of diagnosis or drug doses should be undertaken and references should always be made to the approved prescribing information for any product or procedure prior to its use. Articles which have been published, become the property of FOGSI and should not be published or reproduced in full or in part without the permission of the Editors. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic mechanical, photographing, recording, or otherwise without the prior written permission of the Editors of the book. As far as possible we have tried to incorporate the Vancouver System of references. However, since we are in transitional phase in some articles we could not incorporate the same. Editors
3. 3. Principles and Practice of Obstetrics and Gynecology for Postgraduates Editors Pankaj Desai MD FICMCH FICOG President FOGSI Consultant Obgyn Specialist Janani Maternity Hospital, Baroda, India Narendra Malhotra MD FICOG Consultant and Director MNMH (P) Ltd., Agra Apollo Pankaj Hospital (P) Ltd., Agra, India President, Federation of Obstetric and Gynecological Societies of India 2008 Duru Shah MD FCPS FICS FICOG DGO DFP FICMCH Program DirectorAssisted Fertility Unit, Gynecworld Medical DirectorGynecworld Consultant Obstetrician and Gynecologist Breach Candy Hospital, Jaslok Hospital and Research Center, Mumbai, India JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi Ahmedabad Bengaluru Chennai Hyderabad Kochi Kolkata Lucknow Mumbai Nagpur A FOGSI Publication Third Edition
4. 4. Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd B-3 EMCA House, 23/23B Ansari Road, Daryaganj New Delhi 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672 Rel: 32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: jaypee@jaypeebrothers.com Visit our website: www.jaypeebrothers.com Branches 2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380 015, Phones: +91-079-26926233, Rel: +91-079-32988717 Fax: +91-079-26927094, e-mail: ahmedabad@jaypeebrother.com 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, Rel: +91-80-32714073 Fax: +91-80-22281761, e-mail: bangalore@jaypeebrothers.com 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089 Fax: +91-44-28193231, e-mail: chennai@jaypeebrothers.com 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498, Rel:+91-40-32940929 Fax:+91-40-24758499, e-mail: hyderabad@jaypeebrother.com No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road Kochi 682 018, Kerala, Phones: 0484-4036109, +91-0484-2395739, +91-0484-2395740 e-mail: kochi@jaypeebrothers.com 1-A Indian Mirror Street, Wellington Square Kolkata 700 013, Phones: +91-33-22451926, +91-33-22276404, +91-33-22276415 Rel: +91-33-32901926, Fax: +91-33-22456075, e-mail: kolkata@jaypeebrothers.com Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indra Nagar Lucknow 226016, Phones: +91-522-3040553, +91-522-3040554 e-mail:lucknow@jaypeebrothers.com 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: mumbai@jaypeebrothers.com KAMALPUSHPA 38, Reshimbag, Opp. Mohota Science College, Umred Road Nagpur 440 009 (MS), Phones: Rel: 3245220, Fax: 0712-2704275 e-mail: nagpur@jaypeebrothers.com Principles and Practice of Obstetrics and Gynecology for Postgraduates 2008, Federation of Obstetric and Gynaecological Societies of India (FOGSI) All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the contributors, FOGSI, and the publisher. This book has been published in good faith that the materials provided by contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition : 1996 Second Edition : 2003 Third Edition : 2008 ISBN 978-81-8448-215-7 Typeset at JPBMP typesetting unit Printed at Ajanta Offset
5. 5. To our teachers for teaching us the art and science of obstetrics and gynaecology and for their major contribution in making us what we are today our patients for their unstained faith in us, which has helped us to develop our vast clinical experience and self confidence our students who continue to stimulate us to be researchers, teachers as well as students our families for their support and for tolerating our repeated stints at various works and for sharing their personal family time and of course for supporting us and for always encouraging us FOGSI for giving us an opportunity to express ourself and to serve science and humanity Editors of Third Edition Pankaj Desai Narendra Malhotra Duru Shah
6. 6. Preface to the Third Edition As a part of Gyan Abhiyaan (Knowledge Campaign) we at the team of FOGSI Cares 2007 undertook many and varied knowledge campaigns. This book is one part of that campaign. Our aim in getting this latest edition of the book was principally to generate a top-class first reference-book in the subject for PG students and practitioners. The subjects selected and the contributors have therefore been carefully selected as per their expertise and standing in the subject. We have always felt that the doctor who does not read has no advantage over someone who can not read. They say knowledge, money and water should flowlest they stink. We sure on referring this book the readers will be able to refresh their knowledge keep it flowing. This book is the culmination of thoughts and work done by our own FOGSI members who know the pulse of the Indian women. Their clinical experience on the various health issues related to our women is immense and invaluable. We thank them immensely for their contribution without which the book would have no meaning. We are confident that our postgraduate students would benefit tremendously from this updated version of the Textbook of Obstetrics and Gynecology by FOGSI. Pankaj Desai Narendra Malhotra Duru Shah
7. 7. Preface to the First Edition The field of Obstetrics, Gynecology and Family Welfare is a dynamic one. The truisms of yesterday are the questions of today and hopefully, the truths of tomorrow. In this age of rapidly growing information and technology, there have been many noteworthy advances in the recent years which have had a major impact on the practice of Obstetrics and Gynecology Changing social and cultural environment has brought with it different needs and expectations of the society from our specialty. New technologies for diagnosis, treatment and prevention of disorders of the fetus have burgeoned in modern obstetrics, which has grown from the concept of merely assisting childbirth into a highly specialized field. The fetus as a patient has now become a reality for the obstetricians. Principles and Practice of Obstetrics and Gynecology is the product of our attempt to advance these objectives. This book has been written keeping in view the latest concept in the understanding of various obstetrics and gynecological conditions as well as their management, without omitting the basic principles and their applied pathophysiology. The text covers extensively topics relevant to the Indian context, like malaria, jaundice and other infections in pregnancy, which are rampant in the developing countries. Management of obstructed labor and the art instrumental delivery is still pertinent in our setup. These are dealt with by the masters of these old and dying skills. The reader is also appraised of the state-of-the-art technology in modern obstetrics and gynecology involving transvaginal ultrasonography, color Doppler, fetal surveillance and intrauterine interventions. The concept of auditing maternal morbidity and mortality has also been introduced to lay a firm foundation of clinical research and promote a logical approach in stead of blindly following the traditional and irrational practices. The authors have done a meticulous survery of the current literature and have amalgamated it with their rich experience to make the text a pleasurable reading. It has been our endeavor to see that the content of this book is both current and comprehensive; and this volume serves as a basic textbook for the postgraduates and as a handy reference for the practitioners. In order to be a teacher, one must always be a student. Compiling and editing this book has been a personal learning experience. Kamal Buckshee Vasant B Patwardhan Rustom P Soonawala (1996)
8. 8. List of Contributors AK Debdas Jamshedpur Chapter 64 Abha Majumdhar New Delhi Chapter 80 Aditi Singhi Mumbai Chapter 117 Alka Kriplani New Delhi Chapter 118 Alka Saraswat Agra Chapters 16, 54 Alok Vashishtha Haridwar Chapter 17 Alokendu Chatterjee Kolkata Chapters 2, 52 Ameet Patki Mumbai Chapter 93 Ameya C Purandare Mumbai Chapter 58 Amitava Mukhopadhyay Kolkata Chapter 66 Amol P Pawar Mumbai Chapter 125 Anand N Bhalerao Pune Chapter 65 Anita Sabharwal New Delhi Chapter 39 Anjali Taneja New Delhi Chapter 50 Anjoo Agarwal Lucknow Chapter 71 Anu Vij Mumbai Chapter 99 Anupam Gupta Agra Chapter 47 Anupama Rao Bangalore Chapter 20 Arti Matah Banaras Chapter 7 Arun Tewari Agra Chapter 60 Asha Oumachigui Pondicherry Chapter 25 Asha R Rao Coimbatore Chapter 79 Ashish Kale Aurangabad Chapter 125 Ashok Khurana New Delhi Chapter 29 Ashwini Bhalerao Gandhi Mumbai Chapters 82, 83, 100 Ashwini Kale Chapter 128 Atul Munshi Ahmedabad Chapters 35, 109 B I Patel Ahmedabad Chapter 96 B K Mitra Durgapur Chapter 67 B L Nayak Sameas Giri Chapter 107 B Shakuntala Baliga Bangalore Chapter 48 BN Chakraborty Kolkata Chapter 90 Barun Sarkar Agra Chapter 12 Basab Mukherjee Kolkata Chapter 122 Beena Chapter 126 Behram S Anklesaria Ahmedabad Chapter 121 Bijit Choudhary Chapter 52 Biju P Cochin Chapter 115 Bimal Moday Mumbai Chapter 100 C B Nagori Ahmedabad Chapter 74 Chandravati Lucknow Chapter 34 CN Purandare Mumbai Chapter 70 D Pushpalatha Hyderabad Chapter 51 Deepika Deka New Delhi Chapters 6,30,120 DK Dutta Kolkata Chapter 46 Dujal Munshi Ahmedabad Chapter 35 Duru Shah Mumbai Chapters 26, 114
9. 9. Principles and Practice of Obstetrics and Gynecology for PostgraduatesX E Sarulatha Chapter 83 Gautam Bhattacharjee Chapter 110 Gautam N Allahabadia Mumbai Chapter 88 Gayatri P Nagpure Chapter 44 Giovanni Miniello Agra Chapter 111 Girija Wagh Chapters 56,63,133 Gita Ganguly Mukherjee Kolkata Chapter 122 Gourisankar Kamilya Kolkata Chapter 62 Harshad Parasnis Pune Chapter 108 Hema Divakar Bangalore Chapter 20 Himangi Warke Mumbai Chapter 69 Hiralal Konar Kolkata Chapters 14,44,81 Hrishikesh Pai Chapter 94 Jaideep Malhotra Agra Chapters 61,91,92,95,96,97,120 Jaya Prakash Shah Chapter 96 Jayant G Mehta Chennai Chapter 87 Jaydeep Tank Mumbai Chapter 59 Joshep Kurian Chennai Chapter 61 Joydev Mukherji Kolkata Chapters 2, 62 Jyotsna Gandhi Mumbai Chapter 27 K Jayakrishnan Kerala Chapter 105 K M Nadkarni Vapi Chapter 60 Kaizad R Damania Mumbai Chapter 13 Kamal Buckshee Noida Chapters 11,12 Kamini A Rao Bangalore Chapters 85,86 Kanan Yelikar Aurangabad Chapters 125, 128 Kavita N Singh Jabalpur Chapter 9 KC Gurnani Shahganj, Agra Chapter 42 KK Das Chapter 67 Konkon Mitra Durgapur Chapter 67 Krishnendu Gupta Chapter 52 Krutika Khopkar Mumbai Chapter 22 Kuldeep Singh New Delhi Chapter 97 Kumud M Ingle Mumbai Chapter 69 Kurush P Paghdiwalla Mumbai Chapter 73 Latha Chaturvedula Chapter 25 M Banumathy Chapter 103 MP Patil Chapter 38 Madhulika Kabra New Delhi Chapter 6 Madhuri A Patel Mumbai Chapter 40 Mahendra N Parikh Chapter 131 Mandakini Megh Chapter 132 Mandakini Parihar Mumbai Chapters 18,49 Maninder Ahuja Faridabad Chapters 4,5 Manish Banker Ahmedabad Chapters 84,89 Manjari Matah Banaras Chapter 7 Manju Mataliya Mumbai Chapter 54 Manju Puri New Delhi Chapter 50 Manu Sobti Mumbai Chapter 72 Markendey Katju New Delhi Chapter 125A Maya Hazra Vadodara Chapter 3 Maya Lulla Mumbai Chapter 101 Maya Sood New Delhi Chapter 39 Meenakshi Bharath Navi Mumbai Chapter 18 Meera Desai Baroda Chapter 43
10. 10. XI Mehroo Hansotia Mumbai Chapter 38 Milind R Shah Sholapur Chapter 57 Monesh Shah Chapter 91 Murad E Lala Mumbai Chapter 100 Murari S Nanavati Mumbai Chapter 31 Nandita Maitra Baroda Chapter 3 Nandita Palshetkar Mumbai Chapter 116 Narendra Malhotra Agra Chapters 61,92,95,96,97 Nayana A Dastur Mumbai Chapter 58 Neera Agarwal New Delhi Chapter 37 Neeraj Gupta New Delhi Chapter 6 Neharikaa Chapter 120 Neharika Malhotra Agra Chapter 61 Nikhil Jani Mumbai Chapter 113 Nikhil Purandare Mumbai Chapter 70 Nivedita Chattopadhyay Kolkata Chapter 2 Nozer Sheriar Mumbai Chapter 53 Nutan Jain Muzaffarnagar Chapter 112 Pankaj Desai Baroda Chapter 21 Parikshit D Tank Mumbai Chapters 13,23 Partha Guharoy Chapter 88 Partha Mukherjee Kolkata, WB Chapters 2,7 Parul J Kotdawala Chapters 75,127 PG Paul Kochi Chapter 115 Picklu Choudhury Chapter 44 PK Sekharan Calicut Chapter 106 PK Shah Mumbai Chapter 95 Prachi Bhikaji Shitut Mumbai Chapter 119 Pradeep Kumar Garg New Delhi Chapter 118 Pradnya Parulkar Mumbai Chapter 78 Prakash Bhatt Surat Chapter 49 Prakash K Mehta Banglore Chapters 1,8 Prakash Trivedi Mumbai Chapter 117 Prakash V Pawar Mumbai Chapter 125 Pranay Shah Mumbai Chapter 102 Pratap Kumar Manipal Chapter 55 Pratima Anajaria Chapter 36 Pravin M Patel Ahmedabad Chapters 84, 89 Preeti Matah Agra Chapter 7 Priti Kumar Lucknow Chapter 34 Purnima Chatterjee Kolkata Chapter 66 Purvi Patel Baroda Chapter 21 Rahul Wani Chapter 129 Rajendra Singh Pardeshi Aurangabad Chapter 125 Rajyashri Sharma Aligarh Chapter 33 Reena Chapter 126 Richa Singh Chauhan Agra Chapters 104,105 Rishma Pai Mumbai Chapter 116 Ritu P Khiwal Chapter 39 R N Goel Agra Chapter 125B Rohit V Bhatt Chapter 130 Roopa J Pai Coimbatore Chapter 79 Ruchira Menka Jha New Delhi Chapter 76 Sadhana Desai Mumbai Chapters 49,88 List of Contributors
11. 11. Principles and Practice of Obstetrics and Gynecology for PostgraduatesXII Safala Shroff Mumbai Chapters 26,114 Sakshi Tomar Chapters 95,96 Saloni Nanavati Mumbai (Mampal) Chapter 31 Sanjay B Rao Chapter 124 Sanjay Gupte Pune Chapters 63, 123 Sanjay Munshi Ahmedabad Chapter 109 Sarita Bhalerao Mumbai Chapter 24 Sarita S Mehendale Pune Chapter 15 Satyen Kasabwala Cochin Chapter 115 Saunitra Inamdar Chapter 44 Seema Jain Mumbai Chapter 26 Shaheen Aligarh Chapter 33 Shalini Rajaram New Delhi Chapter 37 Shashikant Umbardand Mumbai Chapter 119 Shirish N Daftary Mumbai Chapter 32 Shirish Patwardhan Pune Chapters 56,133 Shirish S Sheth Mumbai Chapter 73 Shyam Desai Mumbai Chapter 113 SK Giri Cuttack Chapter 107 Snehamay Chaudhuri Kolkata Chapter 81 Sonal Karia Ahmedabad Chapter 70 Sonal Panchal Ahmedabad Chapters 28,98 Sonali Tank Mumbai Chapter 41 Soundra Raghavan Chapter 126 Sreelakshmi Chapter 55 Subhash M Nargolkar Pune Chapter 65 Subrat Lall Seal Kolkata Chapter 62 Suchitra Pandit Mumbai Chapters 119, 124 Sudip Chakraborty Kolkata Chapter 68 Sujal Munshi Chapter 89 Sukanta Misra Chapter 45 Sukhpreet Patel Mumbai Chapter 114 Sulochana Gunasheela Bangalore Chapter 77 Sumita Mehta New Delhi Chapter 37 Sunil Bansal Agra Chapters 10,12 Sushma Gupta Chapter 47 Swasti New Delhi Chapter 76 Sylvia DCosta Mumbai Chapter 117 Tanya B Rohtagi New Delhi Chapters 11,12 Tarun Kr Ghosh Kolkata Chapter 66 Tejas Dave Chapter 89 Tejshree Singh New Delhi Chapter 80 Thankam R Verma Chennai Chapter 87 Trupti Nadkarni Mumbai Chapter 24 Uday Thanawala Navi Mumbai Chapter 22 Uma Vaidyanathan New Delhi Chapter 120 Urvashi Prasad Jha New Delhi Chapter 76 Usha B Saraiya Mumbai Chapters 40,101,111 Usha R Krishna Mumbai Chapter 78 Vandana Chadda New Delhi Chapter 19 Vandana G Shetty Mumbai Chapter 82 Vandana Walvekar Mumbai Chapter 36 Vijay C Pawar Mumbai Chapters 93,119,124 Vijay Mangoli Chapter 88 Vimla P Pawar Mumbai Chapter 125 Vinita Das Lucknow Chapter 71 Vivek M Joshi Pune Chapter 65
12. 12. SECTION 1: PREPREGNANCY CARE 1. Preconception Care ................................................. 3 Prakash K Mehta 2. From Safe Motherhood to Reproductive Child Health............................................................. 8 Alokendu Chatterjee, Joydeb Mukherjee, Partha Mukherjee, Nivedita Chattopadhyay 3. Principles of Antenatal, Intranatal and Postnatal Care at First and Second Referral Centers ....... 14 Maya Hazra, Nandita Maitra 4. Changing Trends in Maternal Nutrition and Interventions .................................................. 19 Maninder Ahuja 5. Maternal Exercises, Yoga and Dance Therapy....................................................... 39 Maninder Ahuja 6. Genetic Counseling for Obstetricians .............. 54 Deepika Deka, Neerja Gupta, Madhulika Kabra SECTION 2: MEDICAL DISORDERS IN PREGNANCY 7. Anemia in Pregnancy ........................................... 69 Manjari Matah, Partha Mukherjee, Arti Matah, Preeti Matah 8. Hematological Problems in Pregnancy............. 88 Prakash K Mehta 9. Hemoglobinopathies in Pregnancy ................... 94 Kavita N Singh 10. Hypertension in Pregnancy............................... 100 Sunil Bansal 11. Cardiac Disease in Pregnancy .......................... 108 Tanya B Rohatgi, Kamal Buckshee 12. Diabetes in Pregnancy: Current Concepts ..... 115 Tanya B Rohatgi, Kamal Buckshee, Sunil Bansal, Barun Sarkar 13. Liver Disease in Pregnancy ............................... 124 Kaizad R Damania, Parikshit D Tank 14. Malaria in Pregnancy ......................................... 128 Hiralal Konar 15. Thrombophilia in Pregnancy............................ 135 SS Mehendale 16. Pregnancy and Renal Disease........................... 143 Alka Saraswat Contents 17. HIV Infection in Pregnancy .............................. 152 Alok Vashishtha 18. Recurrent Spontaneous Abortions: Current Choices in Treatment ......................................... 164 Mandakini Parihar, Meenakshi Bharath SECTION 3: FETUS AS A PATIENT 19. Prenatal Diagnosis and Therapeutic Procedures ..................................... 175 Vandana Chadda 20. Fetal Infections .................................................... 181 Hema Divakar, Anupama Rao 21. Recent Trends in the Management of Recurrent Pregnancy Wastage .......................... 191 Pankaj Desai, Purvi Patel 22. Intrauterine Growth Restriction Diagnosis and Management ........................................................ 203 Uday Thanawala, Krutika Khopkar 23. Controversies in the Management of Twin Pregnancies ................................................ 212 Parikshit D Tank 24. Preterm Premature Rupture of Membranes .. 216 Sarita Bhalerao, Trupti Nadkarni 25. Current Trends in the Management of Preterm Labor ...................................................................... 221 Asha Oumachigui, Latha Chaturvedula 26. New Approach to Management of Rhesus Allo-immunization ............................................. 230 Duru Shah, Safala Shroff, Seema Jain 27. Fetal SurveillanceNewer Developments ...... 242 Jyotsna Gandhi 28. Fetal Echocardiography...................................... 249 Sonal Panchal 29. The Genetic Sonogram ...................................... 269 Ashok Khurana 30. Fetal TherapyMedical and Surgical .............. 275 Deepika Deka SECTION 4: INTRAPARTUM MANAGEMENT 31. Place of Induction of Labor in Modern Obstetrics .............................................................. 295 Murari S Nanavati, Saloni Nanavati 32. Modern Management of Labor ........................ 299 Shirish N Daftary
13. 13. Principles and Practice of Obstetrics and Gynecology for PostgraduatesXIV 33. Intrapartum Fetal Monitoring Controversies.. 308 Rajyashri Sharma, Shaheen 34. Management of Obstructed Labor at a Referral Center .................................................... 318 Chandrawati, Priti Kumar 35. Instrumental Vaginal Delivery ........................ 328 Atul Munshi, Dujal Munshi 36. Modern Management of Breech Presentation.......................................................... 340 Vandana Walvekar, Pratima Anjaria 37. Changing Trends in Cesarean Section............ 346 Neera Agarwal, Sumita Mehta, Shalini Rajaram 38. Active Management of Third Stage of Labor 351 MP Patil SECTION 5: POSTPARTUM CONDITIONS 39. Management of Postpartum Hemorrhage ...... 357 Maya Sood, Ritu P Khiwal, Anita Sabharwal 40. Puerperal Sepsis .................................................. 365 Madhuri A Patel, Usha B Saraiya 41. Breastfeeding Promotion ................................... 373 Sonali Tank 42. Postpartum Psychiatric Disorders ................... 378 KC Gurnani 43. Postpartum Exercises.......................................... 384 Meera Desai 44. Postpartum Collapse .......................................... 391 Hiralal Konar, Saunitra Inamdar, Picklu Choudhury, Gayatri P Nagpure SECTION 6: EMERGENCIES IN PREGNANCIES 45. Antepartum Hemorrhage .................................. 403 Sukanta Misra 46. Tumors during PregnancyManagement ..... 420 DK Dutta 47. Surgical Emergencies during Pregnancy ........ 423 Anupam Gupta, Sushma Gupta 48. Critical Care in Obstetrics: An Overview ...... 431 B Shakuntala Baliga 49. Emergency Obstetric Care for Reducing Maternal Mortality ............................................................... 441 Sadhana Desai, Prakash Bhatt, Mandakini Parihar SECTION 7: FAMILY WELFARE AND CONTRACEPTION 50. History and Development of Contraception....................................................... 449 Manju Puri, Anjali Taneja 51. Natural Methods of Family Planning Barrier Contraception ......................................... 454 D Pushpalatha 52. Steroidal Contraception and Nonsteroidal Contraception.............................. 457 Krishnendu Gupta, Bijit Chowdhury, Alokendu Chatterjee 53. Abortion Practices in India ............................... 468 Nozer Sheriar 54. Complications and Sequelae of MTP ............. 473 Alka Saraswat, Manju Mataliya 55. Permanent Methods of Sterilization ............... 481 Pratap Kumar, Sreelakshmi 56. Social Work in Modern Medicine ................... 487 Girija Wagh, Shirish Patwardhan 57. Intrauterine Contraceptive Device .................. 490 Milind R Shah 58. Emergency Contraception ................................. 502 Nayna A Dastur, Ameya C Purandare 59. MTP ActInterpretation and Implications... 509 Jaydeep Tank 60. Vasectomy and Male Partner Involvement in Family Planning and Welfare ...................... 513 KM Nadkarni, Arun Tewari SECTION 8: GENERAL GYNECOLOGY 61. Approach to Abnormal Uterine Bleeding ...... 519 Jaideep Malhotra, Narendra Malhotra, Joshep Kurian, Neharika Malhotra 62. FibroidsEpidemiology, Etiopathophysiology and Diagnosis ...................................................... 528 Joydev Mukherji, Gourisankar Kamilya, Subrata Lall Seal 63. Current Management of Fibroid ...................... 534 Girija Wagh, Sanjay Gupte 64. Prolapse: Pathological Anatomy and its Bearing to the Selection of its Treatment ....... 546 AK Debdas 65. Current Trends in the Management of Prolapse ................................................................. 555 Subhash M Nargolkar, Anand N Bhalerao, Vivek M Joshi 66. Pelvic Inflammatory Disease ............................ 563 Purnima Chatterjee, Tarun Kr Ghosh, Amitava Mukhopadhyay 67. Ectopic PregnancyCurrent Concepts ........... 568 KK Das, BK Mitra, Konkon Mitra 68. Endometriosis ...................................................... 577 Sudip Chakravarti 69. Urinary Tract Infection in Women .................. 587 Kumud M Ingle, Himangi Warke 70. Stress Urinary Incontinence.............................. 596 CN Purandare, Sonal Karia, Nikhil Purandare
14. 14. XV 71. Genital Fistula ..................................................... 606 Vinita Das, Anjoo Agarwal 72. Genitourinary Fistula Repair............................ 612 Manu Sobti 73. Decision Making for the Choice of Hysterectomy ....................................................... 620 Shirish S Sheth, Kurush P Paghdiwalla SECTION 9: ENDOCRINOLOGY 74. Female Endocrinology and its Clinical Relevance .............................................................. 635 CB Nagori 75. Disorders of Menstruation in Adolescent Age .................................................... 646 Parul J Kotdawala 76. Hormone Therapy (HT): Current Concepts ... 655 Urvashi Prasad Jha, Ruchira Menka Jha, Swasti 77. Management of Hyperprolactinemia .............. 670 Sulochana Gunasheela 78. Polycystic Ovary Syndrome and Hirsutism... 676 Usha R Krishna, Pradnya Parulkar 79. Luteal Phase Inadequacy ................................... 687 Asha R Rao, Roopa J Pai 80. Hyperandrogenism ............................................. 694 Abha Majumdar, Tejshree Singh 81. Thyroid and Adrenal Disorders in Gynecology........................................................... 702 Snehamay Chaudhuri, Hiralal Konar 82. Clinical Approach to Primary Amenorrhea ... 709 Ashwini Bhalerao Gandhi, Vandana G Shetty 83. Precocious Puberty Clinical Dilemmas in Practice .......................... 716 Ashwini Bhalerao Gandhi, E Sarulatha SECTION 10: INFERTILITY 84. Basic Management of Infertility ..................... 723 Manish Banker, Pravin M Patel 85. Induction of Ovulation ...................................... 731 Kamini A Rao 86. Premature Ovarian Failure ................................ 737 Kamini A Rao 87. Male Factor in Infertility ................................... 743 Jayant G Mehta, Thankam R Varma 88. Intrauterine Insemination Current Perspective ............................................ 750 Sadhana Desai, Partha Guharoy, Mehroo Hansotia, Gautam N Allahbadia, Vijay Mangoli 89. Tubal Factors in Infertility ................................ 758 Pravin M Patel, Manish Banker, Tejas Dave, Sujal Munshi 90. Reconstructive Surgery in Infertility .............. 765 BN Chakravarty 91. Overview of ART ................................................ 779 Monesh Shah, Jaideep Malhotra 92. CloningCurrent Research .............................. 795 Narendra Malhotra, Jaideep Malhotra 93. Stem Cell Research ............................................. 812 Ameet Patki, Vijay Pawar 94. Lasers in Human Reproduction ....................... 821 Hrishikesh Pai SECTION 11: IMAGING IN OBSTETRICS AND GYNECOLOGY 95. Ultrasonography in Gynecology ...................... 833 PK Shah, Narendra Malhotra, Sakshi Tomar, Jaideep Malhotra 96. Obstetric Ultrasound .......................................... 858 Narendra Malhotra, Sakshi Tomar, Jaya Prakash Shah, BI Patel, Jaideep Malhotra 97. Color Doppler in Decision Making for Delivery................................................................. 877 Narendra Malhotra, Kuldeep Singh, Jaideep Malhotra 98. 3D and 4D US in Obstetrics and Gynecology........................................................... 885 Sonal Panchal 99. CT-MRI in Obstetrics and Gynecology .......... 903 Anu Vij SECTION 12: ONCOLOGY 100. Surgical Management of Vulvar Tumors ....... 917 Ashwini Bhalerao Gandhi, Murad E Lala, Bimal Mody 101. Cervical Intraepithelial Neoplasia: Diagnosis and Management ........................................................ 923 Maya Lulla, Usha B Saraiya 102. Downstaging of Cervical Cancer ..................... 931 Pranay Shah 103. Surgical Treatment of Cervical Cancer ........... 939 M Banumathy 104. Ovarian TumorsEpidemiology and Classification ....................................................... 944 Richa Singh Chauhan 105. Ovarian CarcinomaClinical Features/ Diagnosis/Principles of Treatment .................. 947 K Jayakrishnan, Richa Singh Chauhan 106. Gestational Trophoblastic Disease.................. 954 PK Sekharan 107. Endometrial Carcinoma ..................................... 971 SK Giri, BL Nayak 108. Germ Cell Tumors .............................................. 981 Harshad Parasnis Contents
15. 15. Principles and Practice of Obstetrics and Gynecology for PostgraduatesXVI 109. Radiation Therapy in Gynecological Cancer .................................................................... 989 Atul Munshi, Sanjay Munshi 110. Role of Chemotherapy in Gynecologic Malignancies ...................................................... 1001 Gautam Bhattacharjee 111. HPV Infection and its Role in Cervical Cancer .................................................................. 1006 Usha B Saraiya, Giovanni Miniello SECTION 13: ENDOSCOPY 112. Diagnostic Endoscopy in Gynecology (Laparoscopy and Hysteroscopy) ................... 1015 Nutan Jain 113. Endoscopy in Infertility ................................... 1030 Shyam Desai, Nikhil Jani 114. Laparoscopic Electrocauterization of Ovarian Surface (LEOS) .............................. 1035 Duru Shah, Safala Shroff, Sukhpreet Patel 115. Widening Horizons of Operative Laparoscopy ....................................................... 1048 PG Paul, Satyen Kasabwala, P Biju 116. Hysteroscopy in Infertility .............................. 1060 Nandita Palshetkar, Rishma Pai 117. Laparoscopic Hysterectomy Current Concepts .............................................. 1070 Prakash Trivedi, Aditi Singhi, Sylvia DCosta 118. Complications of Endoscopic Surgery in Gynecology .................................................... 1098 Pradeep Kumar Garg, Alka Kriplani SECTION 14: MISCELLANEOUS 119. Menopause: A Phase in Womans Life ......... 1111 Suchitra Pandit, Shashikant Umbardand, Vijay C Pawar, Prachi Bhikaji Shitut 120. Applications of Genetics in Modern Obstetrics and Gynecology ............................. 1122 Deepika Deka, Uma Vaidyanathan, Jaideep Malhotra, Neharikaa 121. Breast and the Gynecologist ......................... 1143 Behram S Anklesaria 122. Medicolegal Aspects of Obstetric Practice 1150 Gita Ganguly Mukherjee, Basab Mukherjee 123. Medicolegal Deficiencies in Gynecological Practice................................... 1156 Sanjay Gupte 124. Audit in Obstetrics and Gynecology .......... 1159 Suchitra N Pandit, Vijay Pawar, Sanjay B Rao 125. The Obstetrician and Gynecologist and the Indian Laws ..................................................... 1166 Prakash V Pawar, Kanan Yelikar, Rajendrasingh Pardeshi, Amol P Pawar, Ashish Kale, Vimla P Pawar 125A. Medical Negligence ....................................... 1179 Markandey Katju 125B. Legal Forms and Registrations for Medical Practice in India ............................ 1194 RN Goel 126. Immunotherapy in Obstetrics and Gynecology ...................................................... 1227 Soundara Raghavan, Beena, Reena 127. Fluid Management in Labor ......................... 1233 Parul Kotdawala 128. Female Feticide in India ................................ 1238 Kanan Yelikar, Ashwini Kale 129. Blood and Blood Component Transfusion 1240 Rahul Wani 130. How to Answer Questions in Theory and Viva in Postgraduate Examination? ............ 1244 Rohit V Bhatt 131. How to Write a Paper for Publication ? ...... 1247 Mahendra N Parikh 132. How to become a Good Doctor: Ethics in Obstetrics and Gynecology .......... 1252 Mandakini Megh 133. FOGSI as a Brand for Womans Health ..... 1255 Girija Wagh, Shirish Patwardhan Index .................................................................. 1259
16. 16. Section1 Preconception Care 1
17. 17. Section1 Preconception Care 3 1 Preconception CarePreconception CarePreconception CarePreconception CarePreconception Care Prakash K Mehta INTRODUCTION The health care offered before conception in order to optimize the outcome of a given pregnancy constitutes the preconception care. It is the preventive care for women of reproductive age and their partners, including assessment by history and physical exam, counseling, education and intervention. Achieving good health before conception helps women to have healthier pregnancies with fewer complications. The continuity of care and the close physician-patient relationship in primary care offers an opportunity for the physician to assess risk factors and to intervene and modify behaviors that increase pregnancy risk.1 Education of males is also important since they often influence health risks and behaviors in the female.2 Preconception care must begin at least three months before planning a pregnancy.3 Early Trends Until 1941, the placental barrier was believed to protect the developing fetus from adverse exposure to environmental hazards. Studies of birth defects caused by rubella infection during pregnancy disproved this theory. Further progress towards protecting neonatal outcomes has included education and close management of insulin dependent diabetic women before and during pregnancy. This was later extended to various high risk factors existing before pregnancy. The concept was then offered even to normal women as a primary preventive measure because it was realized that a womans health prior to pregnancy is important for successful pregnancy outcome. PRECONCEPTION VISIT4 A preconception visit should include: 1. History including medical history, familys medical background, questions about diet and social habits, such as whether she drinks or smokes, past pregnancies, birth control use, medication and immunizations. 2. General physical examination including height, weight, blood pressure, thyroid, dentition, heart, breasts and signs of asymptomatic underlying disease. 3. Pelvic examination: a. Infection identification: (i) signs of condylomata or herpes (ii) vaginal discharge evaluated for Candida, Trichomonas, and bacterial vaginosis, cervical discharge culture for Gonococci and Chlamydia b. Cervical anomalies c. Pap smear d. Bimanual examination to rule out uterine and adnexal abnormalities. e. Ultrasound assessment in case of any clinical suspicion 4. Laboratory evaluation: CBC, Blood group, Rh type. Infection profile (VDRL, rubella, HIV and hepatitis B surface antigen), blood sugar, urine analysis and in indicated cases hemoglobin electrophoresis and CMV antibody titres. Counseling Implications Medical Disorders Diabetes mellitus, epilepsy, and hyper-tension are amongst diseases where it is worth-while to bring the
18. 18. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates4 disease under optimal control before getting pregnant. In diabetes to prevent early pregnancy loss and congenital malformations, optimal medical care and patient education and training must begin before conception. This is best accomplished through a multidisciplinary team approach. The desired outcome of glycemic control in the preconception phase of care is to lower glycated hemoglobin so as to achieve maximum fertility and optimal embryo and fetal development.5 Acute complications, including history of infections, ketoacidosis, and hypoglycemia and chronic diabetic complications such as retinopathy, nephropathy, hypertension, atherosclerotic vascular disease, autonomic and peripheral neuropathy and associated thyroid disorders need to be investigated. Diabetes management, including insulin regimen, prior or current use of oral glucose-lowering agents, self-monitoring of blood glucose regimens and results, medical nutrition therapy, calorie needs, diet and exercise need to be discussed. Since the safety of currently available oral glucose-lowering agents in pregnancy is not well- established, women with type 2 diabetes who are taking such agents should be switched to insulin therapy for the preconception period and for pregnancy.6 Antihypertensive agents that are safe for pregnancy should be used. Angiotensin converting enzyme inhibitors, -blockers, and diuretics are preferably avoided. Age-related Factors Pregnancy in an adolescent girl encompasses problems in education, medical and social risks. Pregnancy in elderly encompasses another set of problems. Older women are more likely to have health problems, which could adversely affect pregnancy. In addition, previous gynecologic conditions or abdominal surgery may affect the mothers ease in carrying or delivering the baby. For couples in their 30s and 40s considering parenthood, a common concern is the risk of having a baby with a genetic defect. The risk of chromosomal anomalies increases from 1 in 1300 at 24 years to 1 in 100 at 40 years. The patient needs to be counseled regarding the need for invasive diagnostic procedures when pregnancy establishes. Nutrition and Weight Gain A balanced, nutritious diet is advisable before conception and throughout pregnancy. Studies of the Dutch famine during Second World War revealed the vital need for good preconception nutrition to ensure healthy newborns. Maternal nutrition 90-120 days prior to conception is believed to be as critical, if not more, as the early pregnancy nutrition.7 Special attention is required regarding intake of calcium and vitamins, and must include a folate supplement. Folate has been shown to reduce the rate of neural tube defects arising in the first few weeks of pregnancy often before a woman realizes she is pregnant.8 Similarly pantothenate may help in decreasing the incidence of cardiac anomalies. Young women in the current times are depriving themselves of sound nutritional habits to meet social images of feminine beauty. Primary care attempts to address this problem through education and counseling. However, poor nutrition due to poverty may be the single greatest risk factor for many future mothers. The role of client advocacy clearly comes into focus when the connection between poverty and at-risk pregnancy or neonatal outcomes is made. A woman should attempt to reach her ideal body weight (IBW) before conceiving. Women who weigh < 90 percent IBW have increased risk for preterm or low birth weight infants. Women who weigh > 120 percent IBW have increased risk for gestational diabetes or hypertension. Reducing obesity before pregnancy increases the chances of having a healthy pregnancy.9 Eating disorders may cause nutrient deficiencies that should be corrected before pregnancy. The woman must also be informed that vitamin excesses, especially fat- soluble vitamins, may be toxic and possibly teratogenic. Life-style Behaviors Counseling regarding a womans social habits, such as tobacco and alcohol use, is another crucial part of a pre- conception visit. Discontinuing behaviors, which can be harmful to the developing fetus, including quitting smoking at least three months prior to conception is important. Smoking has been shown to influence fertility, cause miscarriage, low birth weight, preterm delivery and is considered a risk factor for sudden infant death syndrome. Birth defects and growth retardation are known risk factors with alcohol consumption. Drinking alcohol beverages can cause fetal alcohol syndrome, a pattern of birth defects that includes mental retardation, cardiovascular, skeletal and facial abnormalities.10 Lower birth weight has been associated with fathers who drank prior to conception and passive smoking is also harmful
19. 19. Section1 Preconception Care 5 to the fetus. Hence the father to be has to be involved in these lifestyle changes. Intake of caffeine containing beverages must also be reduced, as it may delay conception and increase risk of abortion.11 A discussion regarding illicit, prescription and over-the-counter drug use and understanding the harm is also important.9 Environmental Challenges Studies of occupational hazards and their effects currently support a much larger environmental risk of birth defects. Hazard protection for the worker often fails to include the fetus.9 An example of this is the noise protection devices for workers exposed to high levels of noise. Testing of children exposed in utero revealed a three-fold increase in development of a high frequency hearing loss, greater than 4000 decibels. The protective device the pregnant woman wears over her ears does not provide any protection for her developing fetus. Another deficit is the safe levels of chemicals. Heavy metals like lead, copper and mercury, carbon disulfide, acids, and anesthetic gases can affect the developing embryo. With over 50000 chemicals in the market, including household chemicals and insecticides, there are less than 100 animal studies to determine the effect of chemicals on human development. An adults safe level of chemical exposure is believed to be five to ten times higher than fetal tolerances. Fetal vulnerability is due to a high rate of cell division and differentiation, a small relative size, a lack of enzymes to metabolize drugs, and a less efficient excretory system.12 Protection from radiation (X-rays and effect of electro- magnetic radiation) including exposure to it by living near high tensions wires and by use of microwave ovens and video display terminals, needs to be discussed. Knowledge of the dangers of physical stresses and strains to pregnancy are also important. Modern amusement park rides can generate high negative G-forces, which cause shearing affects known to cause placental abruptions. The early pregnancy is largely protein embryonic cells. Proteins undergo great changes at increased temperature. Hence tub bath and infra red heat exposure may be harmful. Infections Rubella infection can cause serious birth defects if contracted during pregnancy. If the patient is not immune to rubella due to a prior episode, she can be vaccinated before pregnancy, but pregnancy should be delayed for three months after vaccination.9 Toxo- plasmosis can seriously affect the fetus. Serological testing to identify immunity is worthwhile in high prevalence areas. A pregnant woman can help avoid contracting toxoplasmosis by not eating undercooked meat or handling cat litter before she becomes pregnant and during pregnancy. All women must be preferably screened for hepatitis B. Uninfected women, especially those at high risk (such as health care workers who handle blood), can get protection from this infectious disease by vaccination. Local infections must be identified and treated before pregnancy is planned. For example, treatment of condylomata acuminata by podophyllin is contraindicated during pregnancy and hence treatment has to be completed before pregnancy. It is particularly important to screen for and treat bacterial vaginosis since it is associated with an increased risk of premature rupture of membranes, preterm birth, and histologic choriomeningitis. Counseling of HIV positive couples regarding pregnancy outcome, antiretroviral drugs, breastfeeding and long-term implications is extremely important. Contraception Usage Few couples are aware that birth control pills should be discontinued several months in advance of pregnancy to allow at least two regular menstrual cycles to occur before conception. Women who take oral contraceptive agents may gain excessive weight and have an increase in serum cholesterol. An intrauterine device should also be removed a few months prior to pregnancy. Limitations and failure rates of various contraceptive methods must be discussed with the couple. Drug Usage Medication use by adult population is extremely common.13 A review of data14 regarding 152531 women who delivered between 1996 and 2000 revealed that in 64% of women, a drug other than a vitamin or mineral supplement was dispensed in the 270 days period before delivery. This included category C drugs dispensed to 37.8% and category D drugs dispensed to 4.8% of women. More over, drugs which are absolutely contraindicated in women who are pregnant (category X) were given to 4.6% of study population. A planned pregnancy helps in averting problems due to drug usage. Fertility Treatment High rate of multifetal gestation in treatments incorporat- ing exogenous gonadotropins and other associated complications and fallouts must be discussed.
20. 20. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates6 Genetic Screening Most couples do not require specific genetic screening before pregnancy. Information about background rate of birth defects needs to be given. However, some couples are at increased risk for genetic problems like Thalassemia or Tay Sachs disease, because of a family history of inherited disease or because of their ethnicity or geographic background. Consanguinity, individuals with abnormal genetic test result and recurrent mis- carriage also require genetic counseling. Prepregnancy counseling is quite important in educating couples and helping them make educated decisions about their risk for birth defects or genetic disorders.12 Advantages of Prenatal Care 1. Identifying the optimal time to try to conceive. 2. Explanation of appropriate testing and procedure options, including risks, benefits and limitations. 3. The importance of getting adequate folic acid, iron and other nutrients both while trying to conceive and in early pregnancy. 4. The dangers of smoking, alcohol, and drug use. 5. A discussion of the patients medical problems and/or those of her partner and its management by team approach. 6. Accurate family and genetic history and identification of risk factors may reduce the incidence of birth defects. 7. Updating womans immunization status . 8. A review of safe activities during pregnancy (e.g., moderate exercise, sex, travel) as well as unsafe ones (e.g. contact sports and first-trimester travel). 9. Individual participation in health care. The woman can maintain control over her life during the process of conception and pregnancy. Protective environment at work and short term transfer from job deemed harmful to pregnancy, may be planned. 10. Pregnancy planning allows women to optimize their reproductive future. The proportion of infants born with a health disadvantage is significantly lower if the pregnancy was intended than if it was mistimed or not wanted. 11. Patient supportfacilitation of informed decision- making is available. Assistance in coping with psycho-social issues, education and coordinated patient care is possible. 12. Early and complete antenatal care becomes a reality because of the continuum of the care process. Changing Dynamics of Responsibility Realistically, although parents want a perfect baby, the physician cannot fulfill this goal every time. Precon- ception care shifts this responsibility back to the parents. Better reproductive outcomes may be achieved with increased education and intervention on many levels.12 Average first prenatal visit occurs 10 weeks after conception when most of fetal organogenesis has already been accomplished, greatly reducing chance for outcome intervention. Pre-conceptual counseling can help increase the odds for a healthy pregnancy and healthy baby. Preconception planning and a risk screening profile at the initiation of care helps the physician to define the client base by risk level and also the ability to pay for medical care. Current Status Many studies9,12 have found that performance is poor in providing preconception counseling. Deficiencies are noted in providing a healthy woman with information on rubella immunization and family planning or counseling on sexually transmitted diseases and safer sex. This warrants correction. The four components necessary for the successful practice of preventive health care including preconception care, that is, attitude, organization, appropriate knowledge and management skills needs to be emphasized during the training of the residents in the field of gynecology. CONCLUSION Preconception care consists of three main components: Risk assessment, health promotion, and intervention. Preconception care and early pregnancy care are excellent opportunities to modify the medical, social and behavioral risks on pregnancy outcomes and should be an integral part of primary care practice. Because over 50 percent of all pregnancies are unplanned, it is imperative that all gynecologists think of themselves as preconception health providers. The benefits are not likely to be fully realized unless primary care physicians include preconception care as a routine intervention for all women of reproductive age in their practice. The need for such care is greater in hospitals that serve large numbers of poor women, since the women most likely to benefit from preconception care, are often those least likely to have access to it.
21. 21. Section1 Preconception Care 7 REFERENCES 1. Gregory KD, Davidson E. Prenatal care: Who needs it and why? Clin Obstet Gynecol 1999;42(4):725-36. 2. Yamey G. Sexual and reproductive health: what about boys and men? Education and service provision are the keys to increasing involvement. BMJ 1999;20;319(7221):1315-16. 3. Koonin LM, Wilcox LS, deRavello L, Gonen JS. Healthy pregnancies start with planning. Bus Health 2001;19(l):55. 4. Konchak PS. Preconception care VITAL MOMa guide for the primary care provider. J Am Osteopath Assoc 2001;101 (2 Suppl):S1-9. 5. Delgado Del Rey M, Herranz L, Martin Vaquero P, Janez M, Juan Lozano Garcia J, Darias R, et al. Role of glycosylated hemoglobin of preconception stage in diabetic pregnancy outcome. Med Clin (Bare). 2001;16;117(2):45-8. 6. Jaffiol C, Baccara MT, Renard E, Apostol DJ, Lefebvre P, Boulot P, et al. Evaluation of the benefits brought by pregnancy planning in type I diabetes mellitus. Bull Acad Natl Med 2000;184(5):995- 1007; discussion 1007-08. 7. JA Heslin, B Natow. Nutrition Needs for the Preconception Period, Occupational Health Nursing 1984;32:469-73. 8. Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database Syst Rev 2000; (2):CD001056. 9. Morrison EH. Periconception care. Prim Care 2000;27(l):1-12. 10. Floyd RL, Decoufle P, Hungerford DW. Alcohol use prior to pregnancy recognition. Am J Prev Med. 1999;17(2):101-07. 11. Leviton, A. Caffeine consumption and the risk of reproductive hazards. J Repro Med 1988;33:175-78. 12. Schrander-Stumpel C. Preconception care: challenge of the new millennium? Am J Med Genet 1999;25;89(2):58-61. 13. Kaufman D, Kelly J, Rosenberg L, Anderson T, Mitchell A. Recent patterns of medication use in the ambulatory adult population of the United States. Jama 2002;287(3):337-44. 14. Andrade SE, Gurwitz JH, Davis RL, Chan KA, et al. Prescription drug use in pregnancy. Am J Obstet Gynecol 2004;191:398-407.
22. 22. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates8 2 From Safe Motherhood toFrom Safe Motherhood toFrom Safe Motherhood toFrom Safe Motherhood toFrom Safe Motherhood to Reproductive Child HealthReproductive Child HealthReproductive Child HealthReproductive Child HealthReproductive Child Health Alokendu Chatterjee, Joydeb Mukherjee, Partha Mukherjee, Nivedita Chattopadhyay Maternal mortality is a truly neglected tragedy. Ninety- nine percent of maternal deaths occur in the developing countries and among women in the most deprived sections of the population. Maternal Mortality (MM) remains one of the most daunting public health problems in India. In the global scenario, according to the WHO there are about 529000 maternal deaths per year with a global ratio of 400 maternal deaths per 100000 live births.1 Around 136000 maternal deaths occur in India (WHO, 2004). National health survey (1998-99) by International Institute for Population Sciences (IIPS) published from Mumbai in 2000, reported MMR at 540, while the Register General Report in 1998 found MMR 470. As high as 80% of maternal mortality is preventable. The women in the developing countries have a lifetime risk of death following complications of pregnancy, about 250 times more than that of the developed countries. The lifetime risk of maternal death in the world on the whole is 1 in 74, which varies from country to country and region to region. In the least developed countries the chances are 1 in 17, in the developing countries the risk are 1 in 61 and in the developed countries the chances are 1 in 4000. Again for every death, there are 10 more that are left with morbidities of various kinds that may have life-long crippling effects which the women endure in silence (Fig. 1). It is very rightly stated that maternal mortality is only the tip of the iceberg of maternal morbidity and womens suffering. Definition and Causes of Maternal Mortality The maternal mortality ratio (MMR) means the number of death of women while being pregnant or during delivery or within 42 days of termination of pregnancy, irrespective of duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes, per 100000 live birth. Although this statistics is often called the maternal mortality rate, it is not really a rate because the numerator (maternal death) is not a part of the denominator (live birth). The causes of maternal death are multiple; they are divided into direct and indirect causes (Tables 1 and 2). Other causes contributing to maternal death are listed in Table 3. Direct obstetric cause (80%)5 are those resulting from obstetric complications of the pregnant state (pregnancy, labor and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above (Table 1). Indirect obstetric deaths (Table 2) are those resulting from a previously existing disease or a disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiological effects of pregnancy. Investigators have found that 63 to 80% of direct maternal deaths and 88 to 98% of all maternal deaths could probably have been Fig. 1: Extent of maternal mortality, morbidity and disabilities2-4
23. 23. Section1 From Safe Motherhood to Reproductive Child Health 9 avoided with proper handling. Indian and global scenarios of maternal deaths are shown in Figures 2 and 3 respectively. Safe Motherhood Initiative (SMI) It is global effort to reduce maternal mortality and morbidity and to reduce maternal deaths by at least half by 2010, Safe Motherhood Initiative (SMI) was conceived in 1987 at Nairobi. It has also aims to enhance the quality and safety of girls and womens lives through adoption of a combination of health and non-health strategies. Partners of safe motherhood initiatives are governments, different NGOs, World Bank, UNICEF, UNFPA, WHO, IPPF, professional bodies and womens group. As a matter of fact anybody and everybody can be a partner of this initiative. It lays emphasis on the need for better and more widely available maternal health services, the extension of family planning, education and services and effective measures aimed at improving the status of women. It may take many forms: Increasing awareness of the magnitude of the problem and the need for action, strengthening maternal health services, training of health workers and others, facilitating educational and economic opportunities for women and research particularly operational research. Strategies of Safe Motherhood If we compare the maternal health scenario between the developed and the developing countries (Tables 4 and 5), it becomes evident at MMR in developed countries is very low compared to developing countries. The reasons for massive reduction of maternal mortality in developed countries and very high in developing countries are given below. Keeping the above information in mind, a strategy (shown in Fig. 4) was taken in India in 1992, called Child Survival and Safe Motherhood (CSSM). Table 1: Direct causes of maternal mortality Sepsis including unsafe abortion Obstetric hemorrhage Eclampsia Accident of labor Others* *Other direct causes include, ectopic pregnancy, anesthesia related causes, embolism, etc. Table 2: Indirect causes of maternal mortality 1. Anemia 2. Associated diseases Cardiac Renal Hepatic Metabolic Infectious (including HIV) 3. Malignancies 4. Accident Table 3: Contributory causes of maternal mortality Poor quality of health services including lack of proper infra structure. Inadequate obstetric care and essential supplies. Poor maternal mortality audit. Illiteracy, early marriage, poverty and malnutrition. Unregulated fertility. Ignorancecauses delay in making decisions during pregnancy. Multiple demands on womans own time. Fig. 2: Indian scenario of maternal death6 Fig. 3: Global scenario of maternal death6
24. 24. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates10 The tip of the pyramid shows health care programs of women for immediate results. Medium and long term goals are also defined. Health Care Interventions The medical profession is responsible for delivering the obstetric health to all pregnant women. Obstetric Health care means three Es. Essential obstetric care for all. Early detection of complications. Emergency obstetric care (EOC). Protocol for Essential Obstetric Care (Fig. 5) It includes focused antenatal care with booking between 12 and 16 weeks with at least 5 visits. Routine blood pressure and weight are recorded, along with obstetrical examination. Mandatory investigations like Hb percent, blood grouping and Rh typing, urine sugar and protein are to be done. Two-hour are postprandial blood sugar may be performed. Each woman is prescribed iron, folic acid and deworming agent after 16th weeks. Immuni- zation against tetanus and proper care at birth must be taken. 5 clean should must be followed during birth care, clean hand, clean surface, clean razor blade, clean cord tie and clean cord stump. These services can be provided by ANM or MO at health center and their local doctor or by trained birth attendant, preferably at the womens locality. All health care providers must know when to refer the women to the nearest referral unit where EOC is availablethis is the most important issue in the management of any obstetric complications, anywhere. Early Detection of Complication It is wise to remember that every pregnant woman is at risk of developing complications any time during pregnancy, labor and puerperium, and most compli- cations cannot be predicted, also many complications cannot be prevented. Quality antenatal care can detect some complications early. It is always the first contact health providers who will detect the complications. In rural area they are trained attendants / nurse midwives, family members and local practitioner. This group must be updated with the knowledge of signs of complications e.g. bleeding anytime during pregnancy, convulsion, high fever, persistent headache and / or blurring of vision, excessive swelling of the body, less amount of daily urine output, prolonged labor pain and excessive bleeding after delivery, etc, and such cases should be referred to the nearest First Referral Unit (FRU). Table 4: Maternal death scenario in developed countries (Low MMR) Better status of women 98% prenatal care Better nutrition 95% institutional delivery Reduced fertility 99% skilled attendance at delivery Improved education Good essential supplies No gender bias Easy access to maternity service Standard health care Improved maternal mortality audit Table 5: Maternal death scenario in developing countries (High MMR) Poor status of women 59% prenatal care High gender bias 37% institutional delivery Illiteracy, ignorance 55% skilled attendance at delivery Early marriage and poverty Poor health care Unregulated fertility Poor access to maternity service Unsafe abortion erratic essential supplies Malnutrition, infection Poor maternal mortality audit Fig. 4: The child survival and safe mother program
25. 25. Section1 From Safe Motherhood to Reproductive Child Health 11 EMERGENCY OBSTETRIC CARE (EOC) The focus of safe motherhood programs in most developing countries has been on delivery of maternal services. The goal of reducing maternal mortality cannot be achieved, if prompt adequate care is not available for obstetric complications. The challenge now is to shift the focus on EOC in addition to ongoing health care program. EOC includes specific interventions to manage specific emergency complications, which can be fatal within hours. It is agreed that 15% of all pregnant women will develop serious complications. Estimated average intervals from onset of complications to death are given in Table 2.6.7 No women should ideally deliver in a place which is more than 2 hours away from a referral unit. Apart from hemorrhage, there is usually enough time for a woman to be saved, supposing four frequent causes of delay are limited: Delay in recognizing the problem. Delay in seeking care. Delay in reaching care. Delay in receiving care. EOC will be of Three Types 1. Obstetric first aid. 2. Basic EOC. 3. Comprehensive EOC. Functions to Define Obstetric First Aid Oral Misoprostol Parenteral oxytocics Parenteral antibiotics Parenteral anticonvulsants. Functions to define Basic EOC (include in Addition to Obstetric First Aid) Manual removal of placenta Forceps or vacuum extraction. Evacuation of uterus in incomplete abortion. IV fluid administration. This can be done in commu- nity health centers. Comprehensive EOC It includes, in addition to the above, facilities for surgery, anesthesia and blood transfusion. The first referral hospital forms vital link between rural community and the centralized district hospital. Maternal mortality can be reduced more by treating the complicated cases earlier and nearer home at first referral hospital either by specialists or by the physicians with 3-5 year experience who possess basic skills in obstetrics and surgery. First Referral Hospital or First Referral Unit It may be an upgraded health center, community health center or may be a district hospital. Staffs here are trained to perform essential obstetric functions (WHO 1986)8. These are follows: Fig. 5: Essential obstetric care Table 6: Time interval between onset of complications and death Condition Interval PPH 2 hr APH 12 hr Rupture uterus 1 day Eclampsia 2 days Obstructed labor 3 days Sepsis 6 days
26. 26. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates12 1. Surgical functionCesarean section, laparotomy for rupture uterus and tubal pregnancy, dilatation and evacuation, amniotomy, oxytocin infusion for augmentation of labor, repair of vaginal or cervical tears. 2. Anesthetic functionsgeneral/regional 3. Medical functionstreatment of shock, sepsis, hypertension, eclampsia, and anemia. 4. Blood transfusion. 5. Manual or assessment functionmanual removal of placenta, vacuum extraction, forceps, partography. 6. Family planningtubectomy, vasectomy, IUD insertion, norplant insertion etc. 7. Management of complicated pregnancy /labor referred from other levels. 8. Neonatal careResuscitation, thermal control and feeding. Doctors, policy makers and health planners need to recognize that the objective of SMI to reduce MMR cannot be achieved by the existing services alone the provision of EOC at all level will be essential to bring about a sizeable decline in maternal mortality. REPRODUCTIVE AND CHILD HEALTH (RCH) PROGRAM Phase I The concept of reproductive health, first introduced by Prof Fathalla, received a global acknowledgement during the International Conference on Population and Development (ICPD, Cairo 1994). ICPD defines Reproductive Health (RH) as a state of complete physical, mental and social well being and not merely the absence of disease or infirmity in all matters relating to the reproductive system, its function and process with a life time perspective. The main issues of RCH program are the integration of all interventions relating to improve facilities of obstetric care, MTP, IUD insertion in the PHCs, specialist centers for STD and RTI in all district hospitals and number of subdivisional hospitals, setting up of first referral unit at subdistrict level providing comprehensive emergency obstetric care, integration of all interventions of fertility regulation, maternal and child health with reproductive health for both men and women. RCH phase I program had incorporated safe motherhood components along with child survivor components including STD and RTI. The RCH program was launched on 15th October, 1997. The RCH program integrated all the services of CSSM and the major interventions like essential obstetric care, 24 hour delivery services at PHCs/CHCs, emergency obstetric care, Medical Termination of Pregnancy, prevention of reproductive tract infection (RTI) and sexually transmitted disease (STD). RCH II This phase II began from 1st April 2005 with a focus to reduce maternal and child morbidity and mortality along with an emphasis on rural health center. The major strategies under the RCH II are: Essential Obstetric Care Institutional Delivery Skilled attendance at delivery Emergency Obstetric Operational First Referral Unit Operationalizing PHCs and CHCs for twenty four hour delivery services. Strengthening of the Referral System Recent initiatives have been taken to provide adequate training of the MBBS doctors in life saving skills for emergency obstetric care. This provision of adequate and emergency obstetric care has been recognized as the most important intervention for saving lives of pregnant women with complications. ROAD AHEAD OF SAFE MOTHERHOOD Comparison of Indian and International initiative to reduce maternal mortality is shown in Table 7. Making Pregnancy Safer (MPS) MPS is a health sector strategy launched by WHO (2000)9 for reducing maternal and perinatal mortality and morbidity. The MPS strategy builds upon the lessons of SMI, existing national efforts and the consensus reached at the ICPD (Cairo 1994), world conference on women (Beijing 1995) and the joint WHO/UNFPA/UNICEF/ WORLD Bank Statement (1999). Table 7: Initiative to reduce maternal mortality International Indian response SMI Nairobi 1987 CSSM 1992 Target to reduce MMR Target to reduce MMR Half by 2000 from 400 to 200 ICPD Cairo 994 RCH 1996 Defined RH RCH-I 1997 MPS 2000 RCH-II 2005-2009 MDG 2000 (Goal 5) RCH-II Target to reduce Target to reduce MMR MMR to 150/100,000 by 3/4th by 2015
27. 27. Section1 From Safe Motherhood to Reproductive Child Health 13 The universally agreed goals in maternal health include: 80% childbirths be assisted by skilled attendants by 2005. In areas with very high MMR, at least 40% of births be assisted by skilled attendants by 2005, 50% by 2010 and 60% by 2015. Reducing pregnancy related mortality by 75% by 2015. Reducing IMR below 35 per 1000 live births by 2015. Three MPS Messages 1. Every pregnancy ought to be wanted. 2. All pregnant woman and their infants should have access to skilled care. 3. Every woman should be able to reach a functioning health facility in good time to obtain appropriate care when complications arise during pregnancy, delivery, or the puerperium period MPS call for following essential services which could prevent up to 80% of maternal and newborn deaths. Family planning information and services. Post-abortion care. Basic antenatal and postpartum care. Skilled attendance during pregnancy, delivery and postpartum period Referral centers for complications. Millennium Development Goals See chapter on Improving Maternal Health in India. The Partnership for Maternal, Newborn and Child Health The partnership is a global health partnership launched in September 2005 and joins the maternal, newborn and child health (MNCH) communities into an alliance of some 130 members to ensure that all women, infants and children not only remain healthy, but also thrive. Ottawa, 21st June 2007A meeting of Canadian and international health professionals was held to discuss why half a million mothers are still dying each year. Certainly, progress has been made in many areas, said Dr. Dorothy Shaw, President of the International Federation of Obstetrics and Gynecology. But it is a humbling experience that on the 20th anniversary of these goals, we still have a half-million women dying every year. Geneva, 15 May 2007The 60th World Health Assembly of the WHO gave prominence to the issue of maternal, newborn and child health. Dar es Salaam, 17 April 2007Prime Minister of Tanzania called on regional leaders to increase health spending to 15% of national budgets and to strive for achieving health MDGs. CONCLUSION The challenge of reducing maternal morbidity and mortality is substantial and there are no simple solutions. The main priority should be for women to have the choice to deliver in any health center or hospital. Ensuring appropriate provision of emergency obstetric care is an essential feature of all intra-partum care strategies, but timely access is crucial. Alternative approach to increase effective intra-partum care strategies is the availability of skilled birth attendants at home. During the last 20 years of international and national advocacy for safe motherhood, an estimated 10 million women have died of maternal causes though 88-98% of maternal deaths are preventable. The FIGO world report 2006 is dedicated to women of all ages and their children, who have lost their lives because their rights were not translated into meaningful action. FIGO, through collaboration with others, is committed to actions that will result in the respect of sexual and reproductive rights and access to health for women throughout the world. REFERENCES 1. WHO (2005). Regional Health Forum 2005;9(1). 2. WHO. The World Health Report 2005: make every mother and child count. Geneva; World Health Organization, 2000. 3. Say L, Pattinson RC, Gulmezoglu M. WHO systemic review of maternal morbidity and mortality: The prevalence of severe acute maternal morbidity (near miss). Reprod Health 2004;1:3. 4. Asford L. Hidden suffering: disabilities from pregnancy and childbirth in less developed countries Http://www.prb.org/ pdf/Hidden Suffering Eng.pdf (accessed Aug 29, 2006). 5. Causes of maternal deaths: global estimates in reduction of maternal mortalityA joint WHO/UNFPA/UNICEF/World Bank statementpublished by WHO: Geneva, 1999. 6. Govt. of India, (Sample Registration System), Maternal Mortality in India; 1997-2003, trends, causes and risk factor, Registrar General, India, New Delhi in collaboration with Center for Global Health Research University of Torrento, Canada. 7. National CSSM program- Complications during antenatal, intranatal and postnatal period, Ministry of Health Family Welfare, Govt of India. 1992;89. 8. Essential obstetric functions at first referral level: Report of a Technical Working Group. Geneva: WHO 1986;8-11. 9. Making Pregnancy SaferA Health Sector Strategy for Reducing Maternal and Perinatal morbidity and Mortality. WHO: Geneva, 2000.
28. 28. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates14 3 Principles of Antenatal, IntranatalPrinciples of Antenatal, IntranatalPrinciples of Antenatal, IntranatalPrinciples of Antenatal, IntranatalPrinciples of Antenatal, Intranatal and Postnatal Care at Firstand Postnatal Care at Firstand Postnatal Care at Firstand Postnatal Care at Firstand Postnatal Care at First and Second Referral Centersand Second Referral Centersand Second Referral Centersand Second Referral Centersand Second Referral Centers Maya Hazra, Nandita Maitra INTRODUCTIONMAGNITUDE OF THE PROBLEM Childbirth is a biological function and an integral part of the social environment, bringing joy to the mother and family. This can turn into a tragedy where a woman loses her child or suffers a catastrophe herself, while performing this social obligation. According to the latest annual report 2005-2006 of the Department of Health and Family Welfare (DoFW), Government of India, the national average of the Maternal Mortality Rate (MMR), i.e. maternal deaths per lakh live births, in the country is 407. Each year in India, roughly 30 million women experience pregnancy and 27 million have a live birth.1 With an estimated 136000 deaths, India has the highest burden of maternal mortality in the world. Most of the maternal deaths are concentrated in the age-group 20-24 years (NFHS-3).2 Forty seven percent of maternal deaths in rural India are attributed to anemia and hemorrhage. Abortions are the third leading single cause of maternal mortality being responsible for 12% of the deaths. According to SRS- 1998,3 sepsis accounts for 16%, obstructed labor for 10% and toxemia for 8% of the total maternal mortality. Regional disparities in maternal and neonatal mortality are wide. It is also recognised that delays in accessing specialised maternal care happens at all levels. Only 42.5% of all births are attended by skilled health staff.2 The estimates of maternal mortality at State/UTs levels not being very robust, MMR can only be used as a rough indicator of the maternal health situation in any given country. Hence, other indicators of maternal health status like antenatal check up, institutional delivery and delivery by trained personnel, etc. are used for this purpose. Nearly two-thirds of the maternal deaths occur in the Empowered Action Group (EAG) States including Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Rajasthan, Jharkhand, Bihar, Orissa and Assam. The MMR was the lowest in Kerala (110), followed by Tamil Nadu (134), Maharashtra (149), Haryana (162), Gujarat (172), Punjab (178), West Bengal (194), Andhra Pradesh (195), Karnataka (228), Orissa (358), Bihar (451), Madhya Pradesh (498), Assam (409), Rajasthan (670) and Uttar Pradesh (707).1 With 16% of the worlds population, India still accounts for over 20% of the worlds maternal deaths. Every five minutes a woman dies of pregnancy-related causes. It is estimated that for each woman who dies, 30 others develop chronic, debilitating conditions that seriously affect the quality of life. TRENDS IN DEVELOPMENT OF HEALTH CARE POLICIES IN INDIA The Ministry of Health and Family Welfare is the apex executive organization dealing with the issues of health and family welfare in the country. It also lays the national health policy in accordance with the policy decisions of the Cabinet. In 1986, WHO convened a Technical Working Group to define the essential obstetric care necessary at first referral level for the reduction of maternal mortality and morbidity, and to describe the staff, training, supervision, facilities, equipment and supplies needed.4 This definition of essential obstetric care at first referral level has been of invaluable service to health planners of maternity services. However, it has not helped to reverse the polarization that has existed for twenty-five years
29. 29. Section1 Principles of Antenatal, Intranatal and Postnatal Care at First and Second Referral Centers 15 between the development of hospital maternity services on the one hand and the training of traditional birth attendants on the other. Two important milestones of the National Health Program of India to reduce maternal mortality were a policy shift from a vertical immunization program to a comprehensive Child Survival and Safe Motherhood (CSSM) initiative, and the strategic programmatic change from a high-risk approach to implementation of essential obstetric care (EOC), including the establishment of first referral units (FRUs). Health units which were either community health centers (CHCs) or subdistrict hospitals were identified to function as FRUs throughout the country. Second referral units consist of the district level hospitals and Medical College Hospitals.5 Subsequently, India accepted the recommendations of the ICPD (1994)6 and in 1997 the Reproductive and Child Health Program7 was initiated, incorporating the components of the CSSM program and including the additional component of sexually transmitted diseases and reproductive tract infections. RCH II: Strategic Choices to Reduce MMR The Reproductive and Child Health (RCH) Programme, which was launched on 15 October 1997, draws its mandate from the Programme of Action of the International Conference on Population and Development, 1994. Under the RCH Programme a comprehensive package of services for family planning, maternal and child health and management of reproductive tract infections, including sexually transmitted diseases is being implemented. The key maternal health strategies under the RCH II phase which began on 1st April 20051, 8 are: Essential obstetric care. Skilled attendance at birth (domiciliary and health facilities). Operationalise emergency obstetric care at FRUs. Strengthen referral systems. Promote institutional deliveries. Safe abortion services at PHC level. The main priority of the RCH-II will be the operationalisation of all CHCs and at least 50% of PHCs to provide 24 hr safe delivery and BEmOC by 2010. EmOC is generally categorized as basic EmOC (BEmOC) and comprehensive EmOC (CEmOC) (Table 1). UN guidelines recommend a minimum of one compre- hensive EmOC facility and four basic EmOC facilities per 500000 population. Under the RCH phase II, two levels of institutions will be targeted: PHCs and CHCs for BEmOC FRUs for CEmOC. Anesthesia for EmOC Training for MBBS MOs One of the principal reasons for the failure of the RCH I programme to operationalise the planned 1748 FRUs was the lack of anesthetic services. DoFW has developed a 14-week course in anesthesia for EmOC for MBBS medical officers (MOs). The first batch completed training at AIIMS last year. By 2010, 4000 MOs will be trained to address the acute lack of anesthetic skills for EmOC at FRUs. Training MBBS MOs in Cesarean Section In view of the non-availability of obstetricians at FRUs, the Federation of Obstetric and Gynaecological Societies of India (FOGSI) has developed an EmOC course including cesarean section for MBBS MOs. This important step in capacity building in CEmOC and operationlisation of FRUs will be implemented in a step- wise manner. A pilot phase will be evaluated before scaling up. The National Population Policy (NPP) adopted by the Government of India in 20009 reiterates the Governments commitment to the safe motherhood programme within the wider context of reproductive health. Among the national socio-demographic goals for 2010 specified by the policy, several goals pertain to safe motherhood, 80% of all deliveries should take place in institutions by 2010, 100% deliveries should be attended by trained personnel, and the maternal mortality ratio should be reduced to a level below 100 per 100000 live births. Table 1: Signal functions of basic and comprehensive EmOC services8 Basic EmOC Comprehensive EmOC Skilled health personnel Skilled health personnel who who can provide: canprovidefullbasicEmOCplus: Parenteral antibiotics Anesthetic services Parenteral oxytocic drugs Surgical services Parenteral anticonvulsants (Cesarean section) Manual removal of retained Safe blood transfusion products services Assisted vaginal delivery
30. 30. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates16 THE NATIONAL RURAL HEALTH MISSION (NRHM) (2005-12) The National Rural Health Mission (NRHM) (2005-12)10 seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. Under this scheme, every village / large habitat will have a female Accredited Social Health Activist (ASHA)chosen by and accountable to the panchayat to act as the interface between the community and the public health system. ASHA would act as a bridge between the ANM and the village and be accountable to the Panchayat. She will be an honorary volunteer, receiving performance-based compensation for promoting universal immunization, referral and escort services for RCH, construction of household toilets, and other healthcare delivery programmes. A key strategy of the Mission is operationalizing 3222 existing Community Health Centers (30-50 beds) as 24 Hour First Referral Units, including posting of anesthetists. COMMUNITY MOBILISATION STRATEGIES8 Learning from the lessons of RCH I, RCH II has evolved innovative strategies to stimulate demand for safe delivery and other RCH services Janani Suraksha Yojana (JSY) JSY is a modified version of the National Maternity Benefit Scheme. Its twin objectives are: To reduce maternal and infant mortality through promotion of institutional deliveries. To protect the female fetus and child. Pregnant women belonging to BPL (below poverty line) are eligible. The pregnant woman choosing institutional delivery receives financial assistance: Assistance (Rs.1500) is provided for cesarean delivery. Transport assistance (Rs.150) is provided to a rural woman for traveling to a health center for delivery. Traditional Birth Attendants (TBAs) who mobilise women for antenatal care, institutional delivery and postnatal care are provided with financial assistance. Vande Mataram Scheme The Government has recently launched a scheme to involve private sector in safe motherhood/FP activities. Under this scheme, the gynecologist members of FOGSI volunteer to provide free outpatient care services (antenatal and families planning) to pregnant women on a fixed day each month. Doctors who are not members of FOGSI are also welcome. Each enrolled Vande Mataram physician is provided a kit, consisting of IFA tablets, condoms, OCs and IUDs by the government for free distribution to patients. The scheme was launched on 9/2/04. The Integrated Management of Neonatal and Childhood Illnesses (IMNCI-Plus) Approach The objectives of IMNCI plus strategy in RCH II are to: Implement, by 2010, a comprehensive newborn and child health package at the level of all subcenters (through ANMs), Primary health centers (through medical officers, nurse and LHVs) and First referral units (through medical officers and nurses). Implement by 2010 a comprehensive newborn and child health package at the household level in 250 districts. Public-Private Partnerships Strong partnerships between the DoFW, GOI, state Government and the NGOs are being encouraged. DoFW will provide technical assistance, the state government will provide leadership to the project, and the private sector will be economically and formally engaged for service delivery to fill in gaps. There is a considerable capacity among private providers (NGOs, medical practitioners and other agencies) which is being explored and operationalised. Such partnerships are particularly likely to be viable in urban areas. RURAL HEALTH CARE SYSTEM THE STRUCTURE AND CURRENT SCENARIO11 Figure 1 shows the rural health care delivery system in India. Subcenters The subcenter is the most peripheral and first contact point between the primary health care system and the community. Each subcenter is manned by one Auxiliary Nurse Midwife (ANM) and one Male Health Worker MPW(M). One Lady Health Worker (LHV) is entrusted with the task of supervision of six subcenters. Subcenters are assigned tasks relating to interpersonal communi- cation in order to bring about behavioral change and provide services in relation to maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programs. The Department of Family Welfare is providing 100% central assistance to all the subcentres in the country since April 2002. There are 144,988 subcenters functioning in the country as on March, 2006.
31. 31. Section1 Principles of Antenatal, Intranatal and Postnatal Care at First and Second Referral Centers 17 provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. A PHC is manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 subcentres. It has 4-6 beds for patients. The activities of PHC involve curative, preventive, primitive and Family Welfare Services. There are 22669 PHCs functioning as on March, 2006 in the country. Community Health Centers (CHCs) CHCs are being established and maintained by the State Government under MNP/BMS program. It is manned by four medical specialists, i.e. Surgeon, Physician, Gynecologist and Pediatrician, supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labor Room and Laboratory facilities. It serves as a referral center for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March, 2006, there are 3910 CHCs functioning in the country. MATERNAL AND CHILD HEALTH SERVICES AT THE PRIMARY AND SECONDARY LEVEL Figure 2 shows the antenatal, intranatal and postnatal services at the PHC and CHC level. Fig. 1: Rural health care system in India Primary Health Centers (PHCs) PHC is the first contact point between village community and the Medical Officer. The PHCs were envisaged to Fig. 2: Maternal and child health services at the PHC and CHC level
32. 32. Section1 Principles and Practice of Obstetrics and Gynecology for Postgraduates18 FUTURE CHALLENGES Many systemic problems in the government, in General and Health and Family Welfare Department in particular, affect the implementation of most health programs, CSSM or RCH being no exception. The goal is to achieve optimal health for all the people, which would allow them to lead socially and economically productive lives. Despite the commitment to the program, enormous health problems still need to be addressed. The major constraints facing the health sector are a lack of resources, large vacancy of posts and frequent transfer of staff, lack of an integrated multi-sectoral approach, insufficient IEC support, poor involvement of NGOs, poor disease surveillance and response systems and a manually operated health management information system. REFERENCES 1. Annual Report, Ministry of Health and Family Welfare, Government of India 2005-2006 2. National Family Health Survey -3. Ministry of Health and Family Welfare, Government of India, 2005-2006. 3. SRS Bulletin, October 1998, published by Office of the Registrar General, India. 4. Rooney C. Antenatal Care and Maternal Health: how effective is it? A review of evidence. Geneva World Health Organization 1992. 5. Child Survival and Safe Motherhood Programme, Review and Assessment: Lessons Learned and Recommendations. An evaluation report prepared for the MOHFW, India, 1996. 6. Report on the International Conference on Population and Development Cairo, 5-13 September 1994, United Nations Population Information Network. 7. Basic Guide to Reproductive and Child Health Programme. Department of Family Welfare, Government of India, 1997. 8. RCH II Document 2. The Principles and Evidence Base for State RCH II Programme Implementation Plans (PIPs) Chapter 1: Improving Health Outcomes. 9. National Population Policy, Ministry of Health and Family Welfare, Government of India, 2000. 10. NRHM 2005-2012 Mission Document, Ministry of Health and Family Welfare, Government of India, 2005. 11. Rural Health Care System in India Bulletin on Rural Health Statistics in India 2006-Special Revised version, Department of Family Welfare, Government of India.
33. 33. Section1 Changing Trends in Maternal Nutrition and Interventions 19 4 Changing Trends inChanging Trends inChanging Trends inChanging Trends inChanging Trends in Maternal Nutrition and InterventionsMaternal Nutrition and InterventionsMaternal Nutrition and InterventionsMaternal Nutrition and InterventionsMaternal Nutrition and Interventions Maninder Ahuja Fig.1: Mother-child dyad Fig. 2: Maternal death watch INTRODUCTION Ancient folklore and medical knowledge emphasize that the mother-child dyad (Fig. 1) is a vulnerable group from a health and nutritional point of view. Nutritionists have shown that these segments not only require more dietary intake but are also more susceptible to adverse health consequences following nutritional deprivation. Global studies have unequivocally demonstrated the association between undernutrition and increased risk of maternal, perinatal and infant mortality and morbidity. Clinical trials of food supplementation to undernourished groups suggest that reduction in morbidity and mortality rates and improvement in birth weight and growth in infancy could be achieved by food supplementation and proper nutrition. But now it is not only deprivation but precon- ceptional obesity also which predisposes mother for various complications as well as various fetal compli- cations and development of metabolic syndrome later on in life. So nutrition in mother has changed from scarcity to adiposity and would have to be studied from various angles. Non Communicable Diseases Other new aspect which is developing in relationship to maternal nutrition and nutrition on the whole is the