Viva voce for normal pregnancy case

H.NEHAFINAL YR MBBS

Roll 57

Under the guidance of Prof.Dr.M.S.Vishwanathan

GOOOOD MORNING

OBJECTIVESHISTORY TAKING

EXAMINATION

IMMUNISATION

HISTORY TAKING

What is the importance of age in pregnancy?

Teenage and >35yrs preg have adverse outcomes

Problems with teenage:› Medical problems: Anemia,malnutrition,pre-

eclampsia› Obetetric problems:fetal

malpresentation,CPD,preterm delivery Problems with pts >35 yrs:

› Fetal : chromosomal abnormalities- downs syndrome,IUGR,malposition,postdated

› Maternal : obesity,PIH,GDM,prolonged labour,lactational failure

When is patient said to be a booked case according to RCH programme?

•1st:20 wks or as soon as she becomes pregnant

•2nd:32 wks or once in 2nd trimester

•3rd:36 wks or once in last trimester

Atleast 3 ANC:

NOTE: A registered pt is not the same as booked case. Registration is done with ANM in a subcentre.

Number of ANC visits ideally?

Once every 4 wks in 1st trimesterOnce every 2 wks in 2nd trimesterOnce every week in 3rd trimester

What does gravity and parity denote?

Gravida: denotes a past/present pregnancy irrespective of gestational age and outcome

Parity: denotes a previous pregnancy beyond the period of viability(>28 wks) irrespective of the outcome

Who is grandmultipara and what are the problems associated with it?

Grand multipara:Birth to atleast 4 viable children Associated prob:

› Malpresentation due to pendulous abdomen› Pronounced lordosis:increases pelvic inclination and

non engagement of fetal head at term› Medical probs: anemia,PIH,GDM› Multiple pregnancy › Placenta previa › Osteomalacic changes leading to contracted pelvis

due to calcium deficiency› Ruptured uterus› PPH

Are EDD and gestational age synonymous? Justify your answer

No it is not synonymous

EDD- depends on last menstrual period

Gestational age-depends on the conception date

What is EDD,conception date,gestational age, menstrual age

EDD: expected date of delivery is the date estimated based on LMP to approx know the due date of birth. It is calculated using

naegele’s formula and modified

naegele’s formula

Conception date: it is the date

when the egg is fertilised. In

normal cycle it is two wks later than the LMP.

Gestational age: “amount of time

the baby is actually

developing” so it is counted from two weeks after

the LMP

Menstrual age: number of

weeks passed from the 1st day

of LMP

How is EDD calculated?

Naegele’s formula: for regular cycles

1st day of LMP+9 mnths +7 days

Modified naegele’s: for irregular cycles

For longer cycles: add the extra days to get

EDD

Eg. Woman with 45 days

cycle and LMP-3.1.12

EDD- 3.1.12+9mnths+7days=10.

10.12 now add the extra

number of days-15 to the

EDD CORRECTED

EDD: 10.10.12+15days=25.10.12

For shorter cycles: subtract the shorter

days to get EDD

Eg. Woman with 20 days

cycle and LMP-3.1.12

EDD-3.1.12+9mnths+7days=10.

10.12 now subtract the shorter days-10 from the

EDD CORRECTED

EDD:10.10.12-10

days=30.11.12

How to determine the reliability of EDD?

Pt should not be using OCP’S

Last three periods should be regular

Clinical history,examination,USG-all correlate with the EDD

To daughters A couple made a deal the night of their Marriage to NOT open the door of

their room to anybody who comes knocking in the morning for any reason!  In the morning the parents of the husband came & knocked on the door, the husband & the wife were looking at each other & as they agreed before, they didn't open the door. After a while the parents of the bride came knocking at the door to check on them, the couple were looking at each other, then the bride dropped a tear & started crying  she said: "I cannot keep them knocking & not open the door, I miss them already"  The husband didn't say anything & he let her open the door for her parents. Years & years passed & the couple had 5 children, the first ones were boys & the 5th was a little girl, when she was born the father was extremely happy that Almighty blessed him with her, & he threw a Huge Party for her in Grand style, people were so amazed with his joy & his happiness that they asked him, why are you so happy with her more than you were before with her elder brothers? He answered simply: "She is the one who will open the door for me"  Baby girls are the comfort of the eyes of their father! They hold the key to their mothers hearts! Daughters are really unique.  They care for their parents even after they are married

. Its rightly said, "A son is a son till he gets a Wife, a daughter is a daughter all her Life!" 

What is the importance of fever with rash in first trimester?

The most worried viral infection is RUBELLA› C/F:

Mild febrile illness Generalised maculopapular rash Arthralgias Arthritis Lymphadenopathy(suboccipital,postauricular,cer

vical) Conjuncitivitis

› May lead to congenital rubella syndrome › Incubation period: 12 to 23 days

What is the significance of UTI in pregnancy?

May lead to:

•Preterm delivery•LBW babies•Pre-eclampsia•Anemia

What is quickening?when does it occur for primi and multi?

It is the perception of fetal movements by pregnant woman

Primi:18-20 wks Multi:2 wks earlier than primi

Recommendation of IFA?

60 mg of elemental iron and 500 mcg of folic acid for 100 days starting in the second half of pregnancy

Folic acid 500 mcg to be started pre-conceptionaly

In women with previously affected children(neural tube defects) what is the dose of folic acid?

4 mg/day

What is the normal weight gain in singleton pregnancy?

It depends on BMI of the ptBMI (pre-pregnancy)

Recommended weight gain(kg)

Low <19.8 12.5-18

Normal 19.8-26 11.5-16

High 26-29 7-11.5

Obese >29 7

Wt gain for twins is 16 -20 kg

How much spacing is required between pregnancies?

Minimum of three years to replenish iron stores of 1000mg

Diet and rest recommendation in normal pregnant woman?

Diet:

Pregnancy-extra 300kcal/day and

10 gm/day protein

Lactation-extra 600 kcal/day and

20 gm/day protein

Rest: 10 hours/day(8 hrs in night and 2 hrs in noon)

EXAMINATION

Leopolds maneuvre??Leopold’s maneuvers

#1 – Correct dextrorotation of the uterus with the back of one hand

and delineate the fundus

with the other to determine gestational age and/or appropriate

size.

#2 – Run hands down

maternal abdomen on either side of

fetus to determine fetal lie,

identifying small parts and fetal

spine

#3 – Firmly grasp upper and lower

poles of fetus by placing fingers at

uterine fundus and above

symphysis to determine

presentation and fetal size.

#4 – Move hands in

bilaterally from anterior superior iliac

crests to determine

whether or not the presenting

part of the fetus is

engaged in maternal pelvis.

Head regarded as unengaged if

examiner’s hands are see to

converge below fetal head.

What is Partogram? the partogram is a graphical

representation of the changes that occur in labour, including cervical dilatation, fetal heart rate, maternal pulse,blood pressure, and temperature; it also shows a numerical record of features such as urine output and the volume and type of intravenous infusions (including oxytocin drips) .

So it helps to identify deviations from normal in any of these variables.

Records of the findings at successive vaginal examination (should be done every 4 hours) are plotted on a graph , showing the dilatation of the cervix in cm against time in hours .

Friedman who introduced the idea of partogram had described two phases of labour :-

1- latent phase : from the onset of labour until the cervix 3 cm dilated which may last 3 to 7 hours in a primigravida .

2- active phase : during which the dilatation from 3 to 10 cm (1cm/h), so the slope of partogram curve will be steeper in this phase .

Latent (a) and active (b) phase of labour in a multiparous and a primiparous woman, as shown on partogram

Monitoring for fetal well-being

What is the abdominal girth at term?

90-100 cms

IMMUNIZATION

When should TT be given?

1st dose- as early as possible

2nd dose- one month after the

first dose

Booster dose only if previously

vaccinated within 3 yrs

How is Rh-isoimmunization given?

1st dose: anti-D

immunoglobulin

prophylactically to

all D-negative mother

at 28 wks

2nd dose: after

delivery within

72 hours if

the infant id D-

positive

NOTE: 2nd dose is given cause

the half life of

immmunoglobulin is 24 hrs and

it persists

for 6 wks

What do you mean by neonatal(NNT)high risk,control,elimination areas

NNT high risk areas:• Incidence: <1/1000• TT 2nd dose

coverage:<70%• Attended

deliveries:<50%

NNT control areas:• Incidence:

>1/1000• TT 2nd dose

coverage:70%-89%

• Attended deliveries:50%-74%

NNT elimination areas:• Incidence:<0.1/1

000• TT 2nd dose

coverage:>90%• Attended

deliveries:>75%

When is rubella vaccine given during pregnancy?

It is not given during pregnancy

•MMR should be given in childhood itself.if not immunised it is given atleast 3 mnths prior to conception

•MMR not given in pregnency cause it is live attenuated vaccine