When should you visit your doctor during pregnancy?

Written by Dr Parul Chopra Buttan

In one of our earlier blog posts, we had talked about things to do and keep in mind when you are planning a pregnancy. This post discusses the visits you should make to your obstetrician during the course of your pregnancy. If you haven’t had the pre-conception visit, then a good time to start is as soon as you realize that you are pregnant.

 

Pregnancy is not a disease! Why see a doctor then?! Well, it's a special physiological state and needs special care. It's important to see the doctor to ensure all is well with both, the expectant mom and the baby, and to take corrective measures when required. Often couples delay the first visit and sometimes, may land up in an emergency with early pregnancy complications.

 

Organised prenatal care (care of an expectant mother) was introduced in United States by social reformers and nurses in 1901. This work of nurse visits to women enrolled in the home delivery service of the Boston Lying-in hospital was so successful that an outpatient prenatal clinic (one of the first) was established in 1911. In 1954, Nicholas J. Eastman credited organised prenatal care with having "done more to save mothers' lives in our time than any other single factor"!

 

We've come a long way since then and can salvage a lot more babies and ensure healthier mothers. Follow this guide to know when you should visit your doctor during pregnancy:

 

1.     Scheduled visits

 

Through the course of pregnancy, there are visits scheduled at regular 3-4 weekly intervals in the early part and as frequent as weekly towards delivery. Every such visit has a specific purpose. We discuss your symptoms, note some points on examination, review the investigations, order some tests and give you a general idea of how it's going medically.

 

It is a wonderful opportunity when you have 100% of the doctor's attention and can discuss any and everything about your pregnancy in detail. Subtle things are also noted by the doctor such as your general well-being, attitude, family support etc. which go a long way in fostering a good rapport based on trust and mutual understanding. In life-changing moments such as the birth of your baby, it is of utmost importance that you place your and your unborn baby's life in the hands of someone you trust to be competent and acting in good faith.

 

Every practitioner has a plan for scheduled visits in pregnancy and it may vary slightly from one to another, though generally the visits are 3-4 weekly in the first 6 months, 2 weekly from the 7th month onwards and weekly in the last 4 weeks prior to the expected date of delivery. Stick to the plan your doctor suggests as it is easier and safer, and there are less chances that something important may be missed.

 

2.     Special visits, for any discomfort you may be feeling out of the ordinary

 

Even a simple cough and cold in pregnancy that doesn't settle in a day or two needs evaluation and merits a visit to the doctor rather than a text or phone call. Infections can be much more severe and complicate faster in pregnancy. If you feel pain or discomfort in the abdomen different from the one your doctor has reassured you about, then you should consult and visit them immediately.

 

Some of the other symptoms could include:

 

-          swelling in one leg or severe swelling in both legs

-          breathing difficulty

-          suspected infection e.g. sore throat, burning in the urine, fever, boil or painful pus filled swelling

-          excessive vomiting

-          inability to keep food down

-          vaginal bleeding or excess discharge

-          decreased fetal movements

-          any other symptom that is persistent or recurrent or worrisome for you

 

Ladies, do not shy away from dropping in to your doctor's clinic for a check-up /chat /reassurance.

 

Wishing you a safe and happy pregnancy!

Kudiyan di Lohri!

Dr Parul Chopra Buttan with her daughter Aanya

I'm not a great fan of the 'selfie' & hardly take one. But on this special evening, I had to click - to chronicle the day I returned to a full-time job after becoming a mother!

As a daughter and the first child in my family, I was my grandparents' and parents' pride, and they put in so much to provide me with the opportunities I have had. I've said this before but what the heck, I'll say it again - as my awesome luck would have it, marriage brought me into a family where those horizons only expanded.
 
I worked hard and completed three post graduate degrees after my marriage (my MS exam was two months after the wedding!), including cracking one of the toughest exams in obstetrics and gynaecology the world over (MRCOG - London).
 
On her first Lohri, my daughter was four months old and exclusively on my feed. That's when I started working again part time, after the maternity break. In the seflies above, she was eight months old and I had taken the the pics the day I joined Max Hospital, Gurgaon, full time as an attending consultant.
 
I'm so grateful for my family and friends who make it all so joyful and rewarding...and possible. I can rush to attend an emergency in the hospital or my clinic at anytime of the day or night; and everything from my baby's care to my food to my car gets arranged!

My mother in law who is a qualified ophthalmologist struggled at my stage as a mother of two, and couldn't practice as much as she would've liked. Result - she ensured every possible help to me and now lives out her 'high flier doctor woman dream' by helping mine come true!
 
My mother who cared for three kids alone for several years (battling a neurological illness with vision deterioration when papa was posted out of station) has been my biggest source of strength, putting in everything she could for our education, especially mine, being touted as the promising child who'd grow up to be a doctor.
 
My father has worked the hardest of us all to get me through medical college – it being as much his ‘tapasya’ as mine. My beautiful little sister has held me through thick and thin, and her wise counsel has always stood me in good stead.

My brother has been my true partner-in-crime through studies and games. My father-in-law has been as much a father to me as to my husband. And my husband is the soul-mate who makes my every dream bigger and his own, to achieve and cherish together.

The effervescent punjabi festival of Lohri takes on an even brighter tone when it marks a family's first Lohri since the arrival of a child. I hope to give my daughter ever widening horizons and pass on the immense love and pride that I've been blessed with. How I wish every daughter would have what I do. I'm living the #KudiyanDiLohri every day and it's a beautiful dream come true!

A daughter brings so much warmth, so much bubbling fulfilment in a family! Being an obstetrician, I'm happy about every baby I ever delivered but these little girls are slightly more special :) 


Aanya with dada and dadi on her first Lohri

 

Five Simple Resolutions for a Healthy = Happy New Year!

by Dr Parul Chopra Buttan

It's that time of the year when we will all bring out our buckets full of lists-to-do next year! The truth is that many of us know already that we won't be able to make them all. But have we paused to wonder why? It's not our resolve that is weak; in many cases it's our bodies.

A healthy body keeps a happy heart and a happening life. Commit to these easy-to-follow health tips and prepare yourself for a spectacular sixteenth year of the century...


1. Plan your day

The first 30 minutes of your day - spend with yourself. Meditate, concentrate, stretch. Use the time to plan your day. Could be a list of to-do tasks you'd like to accomplish or qualities you'd like to manifest. E.g. I'll be kind today. Visualise yourself living the day of your choice and strengthen your self to do the same. Have a similar ten minute 'me time' in the afternoon to check on progress and adjust; and then have another quick one before you go to bed to gather the learnings the day brought, savour the joys and offer thanks. Immensely helpful for reducing stress!

2. Drink plenty of water

Water is the elixir of life, yet we so often do not hydrate ourselves enough. Less water intake contributes to ineffective metabolism, low concentration, obesity, voice abuse, low concentration, urinary infections, tendency to stone formation. Women, because of their body structure are especially prone to urinary tract infections which can be recurrent and troublesome. It's helpful to have set times in the day when you replenish your body with a glass full of clean drinking water. E.g. on waking up, 11am snack time, reaching home from office etc.

3. Say no to smoking

With stress levels going through the roof, smoking in women is on the rise. The new year is a good time to 'kick the butt'. Smoking, besides causing lung cancer, throat cancer, mouth cancer, stomach cancer, bladder cancer amongst other damages is especially harmful to women.
Unbeknown to most youngsters, smoking is associated with ovarian decline and infertility. In pregnancy, it can cause miscarriage, premature birth, growth restriction and stillbirths.

4. Work out

Incorporate some fitness routine into your day. Be it walking, cycling, jogging, running, zumba, pilates, swimming, gymming. It's great to have a fitness buddy to keep up your motivation and add value to your workouts too. You could choose your neighbour, friend, your husband or even your smartphone! It's never too late to begin.  If you are not accustomed to exercise before, do consult your doctor before starting. Start with age and current fitness-level appropriate workout regime and build up gradually.

5. Sign up for health

We ever so often postpone our appointment with the doctor even for a discomfort. Somehow, suffering the tooth sensitivity or the nagging backache seems more tolerable than making the effort to fix it. The woman of the house can hardly afford to fall sick as she carries the whole family through the day, juggling a dozen things! A 'well woman check-up' according to your age and needs is highly recommended. Certain annual checks like the breast examination, pap smear are a small step that go a long way in preventing dreaded diseases like breast and cervical cancer.

Let's make 2016 a healthy one. Let's give our body and mind the care they deserve. Let's take charge of our happiness and start afresh!

Happy New Year!

Surviving miscarriage

Written by Dr Parul Chopra Buttan

I was reading a newspaper report on Paris recently when my inquisitive 2 year old comes by and seeing the picture of a woman crying, asks innocently, "Mumma, aunty kyun ro rahi hain?" Not wanting to thwart her curiosity, I answer despite my discomfort, "because her baby got hurt" [her child was killed]. "Why did the baby get hurt?" I noticed the 'Why' instead of 'How'. That's one deep question, Why? Why do innocent people get hurt? Why does it all happen? Why do we go through this pain of untimely loss?

I couldn't find words and I wasn't prepared for this conversation, so I kissed her and distracted her into a game, much lighter, more age-appropriate for her. But I could sense her disappointment at not getting her answer. I lived with it, mentally making a note to work on an answer and get back better prepared the next time around.

I was dwelling intermittently on this need for an answer to everything, when a conversation with a very intelligent patient of mine happened. She said, "Doctors are like the barrier between us and death, us and mishaps. And when they fail to give us answers, it's deeply disappointing."

Yes, it's 2015. Yes, we are sitting on a mountain of medical research of the past two and a half centuries. But no, we don't have all the answers yet. Our knowledge, even though, has come a long way, certainly has a long way to go. I talked about miscarriage in my last post. In almost 20% of the pregnancies lost early, despite extensive investigations the exact reason for miscarriage may remain unknown. We will not be able to pin the occurrence of a miscarriage on something you did or did not do. We will not be able to justify the guilt you may be feeling or the blame, because it really is nobody's fault.

I'm sorry for the answers we can't provide today. I'm sorry for the pain we can't take away. But here's what we can do. And it is my mission to do my best in this endeavour.

1.     Allow the woman space to feel her emotions

Often, the myriad of emotions a woman may go through, disappointment, guilt, anger, loss, bereavement, grief, get shoved under the carpet. "It's only a miscarriage! People go through much worse!” she is told. Though it is true, much worse horrors are possible and do happen in this miraculous world of making babies, the experience of 'pain' is very individual. Only the wearer knows where the shoe hurts.

2.     Accept her state of mind

Non-judgemental acceptance of the waves of emotions she's going through is paramount to healing. Just when we allow ourselves to feel an emotion rather than resist it, does it flow through us and pass. It resolves, leaving us cleansed. The gynaecologist's chamber should be the one place where the woman can bring up any issue and any doubts around it, any number of times. We will answer them calmly, repeatedly, with the best possible explanation of the current scenario.

3.     Reassurance

Often, the event of losing a pregnancy haunts the woman all through the next one. As gynaecologists, we are happy to repeatedly offer you very encouraging statistical and medical evidence and research, all through the next pregnancy to reassure you. We are in this journey together and our aim of delivering to you a healthy mother and a healthy baby is an oath. We will go the extra mile to ensure your peace of mind, that comes from a qualified professional's true reassurance.

4.     Precautions

Any precautions (physical or otherwise) and medication that may help in reducing the chance of a mishap the next time around – we will discuss in detail to help you make informed choices. Of course, needless medication and restrictions would certainly be discouraged.

5.     Hope

We hope that when the cries and laughter of your magical bundle of joy fills up your home, it drowns the silence of grief you felt for the pregnancy lost.

Life goes on and brings with it a multitude of experiences. Some we're able to make sense of, some just flow through us with a higher meaning, as yet unrevealed.

Miscarriage - what one needs to know

Written by Dr Parul Chopra Buttan

As a passionate obstetrician and a woman myself, I'm pained by the unhappy & uncomfortable situations my patients sometimes find themselves in.

 

Early pregnancy bleeding is one such situation. It wreaks havoc in the mind of the patient and is of grave concern to the obstetrician. I've noticed in my consultations that giving the couple or family complete knowledge about what is going on, what we can expect and what can be done, helps them go through this challenging phase.

 

There are several causes of bleeding in early pregnancy. A sound obstetrician should be able to establish the exact circumstances of your situation by asking you a few questions, doing a gentle, thorough examination and some basic investigations.

 

One of the foremost worries on the mind of the woman and the family is MISCARRIAGE. It is one of the most important and common causes of early pregnancy bleeding, though the only one. The other causes such as ectopic pregnancy, gestational trophoblastic disease, cervical polyp etc merit a separate article and I shall not discuss them further here.

 

This post focuses on miscarriage. There are types and stages to it and most importantly, all is not lost the moment the doctor utters the dreaded word.

1.     THREATENED MISCARRIAGE

The pregnancy is very much alive and intact but is in a vulnerable state. The woman experiences bleeding, usually painless. The site of bleeding may be visible on an ultrasound or may be unknown. Physical exertion needs to be avoided, though bed rest has no role. Pregnancy supportive hormonal medication has an empirical role as per evidence in literature. Medications to control the bleeding may also be given if deemed fit by the gynecologist. At this stage, the pregnancy is salvageable and may continue without any further complications.

2.     INEVITABLE MISCARRIAGE

As the name suggests, miscarriage is unavoidable and usually imminent. The mouth of the uterus may be seen to be open on examination and bleeding is usually heavier than normal menses and often accompanied by pain. The process of expulsion of the pregnancy can be enhanced by medication or by a minor surgical procedure depending on the physical findings and the preference of the patient. Waiting for spontaneous resolution may also be a practical option.

3.     INCOMPLETE MISCARRIAGE

The pregnancy has been partially lost in the usually painful vaginal bleeding and is not salvageable. Again, the remaining part of the pregnancy may be removed with medicines or a surgical procedure depending on the time since bleeding, amount of tissue left behind, any other complications, physical condition of the patient and her preference. There is a risk of anaemia from prolonged heavy blood loss and of infection involving the uterus, converting it into a dangerous septic miscarriage (explained later).

4.     COMPLETE MISCARRIAGE

The whole pregnancy has passed in the bleeding. The bleeding usually reduces significantly and soon stops. Our focus is to provide emotional support and advice on recovery from the event, besides addressing the various questions that arise (why did it happen, when can the patient conceive again, does this episode put future pregnancies at risk… - these questions will be addressed in detail in a separate article.)

5.     MISSED MISCARRIAGE

This entity is usually diagnosed on an ultrasound or if the pregnancy is not seen to be growing clinically. The heart beat is absent and the pregnancy is not salvageable. The woman may have no problems or may experience reduction in the symptoms of pregnancy (such as morning sickness, fatigue etc). Bleeding may begin in some days and start the process of removal of pregnancy or it may remain silent for quite some time. Medicine or a surgical procedure is usually advised when the woman is ready for it. The pregnancy can be sent for testing to know the cause, though in about 40% of the cases, no cause can be found.

6.     SEPTIC MISCARRIAGE

 

It means any kind of miscarriage (spontaneous or voluntary) that has been complicated by infection. It is a serious condition that can quickly become life-threatening by complicating into septicaemia and multi-organ failure. It usually needs prompt management and hospital admission. It may take some time to recover and may even have long term consequences like infertility. Any woman who develops fever, foul smelling vaginal discharge, severe generalised pain in the abdomen while miscarrying should seek urgent medical help.

 

Miscarriage, though not desirable, is a reality. It is one of nature's ways of eliminating the not-so-healthy pregnancies early on. Emotional support and tender loving care from the caregiver and from the family go a long way in restoring the woman's health and long term well-being.

Feed, mother, feed!

Written by Dr Parul Chopra Buttan

Being a woman and a mother, breast feeding my baby has been THE most fulfilling experience of my life. It beats everything...cracking the toughest of exams, performing life-saving surgeries, surpassing the highest highs and overcoming the lowest lows of life… It's just incredible, the experience of being able to nourish a life... And that too, the life you hold dearer than your own!

Women nourish the baby inside of them with their blood every single minute of the nine months during pregnancy, but that is invisible and happening involuntarily. Breast feeding is voluntary, visible and purely magical! Doctors recommend 6 months of exclusive breastfeeding. So all the growth, and it is huge, that you see in your little wonder at this time is through you!

As an obstetrician and gynaecologist, I feel really strongly about this miracle of life. I would urge our community and every family to take utmost care of our women during this precious time.

1. Rest


Give a new mother ample rest. Physically, mentally, emotionally. Give her space and time so she's relaxed and comfortable and can perform this job that nobody else can do. Stress, whether physical, emotional or mental affects milk production and the health of the baby directly.


2. Nutrition

A nursing mother needs about 550 extra calories over and above her daily needs. She should have a balanced diet inclusive of whole grains, fruits, vegetables and plenty of fluids.
 

3. Water

Especially in India, there is a myth that gynaecologists come across often - that water is bad for a nursing mother. I have had so many families in my practice who argue that water dilutes milk and also contributes to a lax tummy post-delivery. It's as far from the truth as can be. Adequate hydration is absolutely essential for milk production, besides guarding against diseases like urinary infections which can be dangerous post delivery.


4. Start early

The baby needs to be put to the breast as soon after delivery as possible, preferably within 1 hour! The baby and the mum, both need to learn the art of breast feeding. This early suckling is what promotes milk production and  ensures the baby gets the all important 'colostrum'. The thick yellowish discharge in the first days after birth is supremely nutritious besides providing the baby protection from diseases such as diarrhoea. So much  so, it is hailed as the baby's first immunisation!! Don't deny this elixir to the baby. Yes, the whole family is excited to hold the newborn. Also, the doctors want to weigh the baby and do their numerous checks to ensure a healthy baby but as far as possible, the newborn baby should be close to the mother and she should be supported in this endeavour. The mother infant bonding at this time goes a long way in ensuring a healthy baby, physically and emotionally!

5. Seek help

If there is anything worrisome regarding the new mother like fever, persistent low mood or anxiety, inability to breastfeed despite trying, painful or swollen breasts, excessive blood loss, tiredness, breathing difficulty, swelling in legs etc., seek help urgently. She needs to see a gynaecologist as soon as possible.

Happy breastfeeding to you!

Letter to Parents-to-be!

Written by Dr Parul Chopra Buttan

Dear mommy and daddy-to-be,

Congratulations on making it this far! You are now about to embark on the final leg of this incredible journey which is also the most exciting and miraculous part of it. By now you would have had a detailed discussion with your doctor regarding the plan of delivery suitable for you according to how your pregnancy has been and your preferences.

Signs of onset of labour/ when to call your doctor?

If you experience any of the following, it's time to call your doctor

1. Pain abdomen - usually regular, rhythmic, intermittent, increasing in intensity& frequency
2. Breaking of waters - this will usually feel like a gush of urine-like fluid leaking out of the vagina. May even begin by small amounts leaking intermittently.
3. Show - a dirty, sticky mucoid discharge may precede pain.
4. Any other symptom you may be concerned about depending on your pregnancy.

Labour

Labour is a slow and exhausting process. The mouth of the uterus opens slowly from zero to ten centimetres (dilatation) and then the baby descends. Any deviation from the normal may necessitate some action on the part of the team caring for you. Your doctor will familiarise you with the various situations that can arise commonly so as to ease the communication and save time during those all important minutes, should an emergency arise. Discuss options for pain relief available and have a plan ready and documented.

Normal delivery

Your doctor will encourage you to push at the right time. You may feel the urge by yourself too. A small cut at the vaginal opening (called episiotomy) may be required to facilitate the delivery safely. The umbilical cord is cut and the baby is handed over to the baby receiving team. The after births are delivered. Some medicines may be administered to reduce blood loss. Your doctor will stitch up the cut under local anesthesia and apprise you of the care of the stitches.

Instrumental delivery

Sometimes, the delivery of the baby may need to be aided with a vacuum cup ( Aamir Khan's character in the Hindi film, 3 idiots does one!) or forceps. Discuss the pros and cons of both the instruments with your doctor beforehand and make an informed choice.

Elective Caesarean birth

In case your delivery is by a pre-planned Caesarean section, your doctor would have discussed the expected procedure and recovery. Usually a spinal anesthesia is used wherein you are awake and pain free and can hear your baby's cry! A different anesthesia may be needed depending on your particular case. Drinking and eating may commence 4-6 hours after the surgery. You will usually be able to get up and walk by the next day. Depending on your recovery and preferences, discharge from the hospital may be planned 1-3 days post surgery.

Newborn care

The baby will usually be cleaned, examined, weighed and covered by the receiving doctor and team. They will let you know about concerns, if any, and their plan of management. Most of the babies can be shifted immediately to the mother's side and you may begin breast feeding as soon as comfortable. If it is your first baby, do familiarise yourself with newborn care with the hospital staff who would be happy to help in all respects.

My best wishes for a safe delivery!

 

Dr Parul Chopra Buttan