Why is physical examination done before deciding about surgery ?
Physical examination helps to decide about the fitness of the patients to undergo surgery. To begin with, information is collected from the patient through questioning about any surgery undergone by the patient before, smoking or drinking habits, history of jaundice during last 6 months, epileptic fits, cough, breathlessness on walking or climbing staircases or at night, excessive bleeding from cuts and wounds, allergy to certain drugs and sun. In the case of a woman, pregnancy details are to be collected.
Why are patients advised to undergo blood, urine examination etc. prior to surgery ?
Pathological examination prior to surgery is conducted mainly for two reasons:
1) To confirm clinical diagnosis through blood examination, X-ray etc, if required.
2) To judge patient’s ability and condition to withstand the stress induced due to surgery and / or anaesthesia. The types of tests required in the first category usually depend upon the type of the suspected illness. In case the operation directly involves vital organs such as the heart, kidney, liver etc. specific and special test are required to determine the conditions of these organs. In case of general operations, some common essentials tests are needed. The type of these routines, essential tests depends upon 3 things:
1) Nature of the operation and type of anaesthesia required
2) Patient’s age and
3) Past and present illness.
Nature of operation and anaesthesia
No surgery should be taken lightly. However, there is certainly a qualitative difference between a heart surgery and a surgery to remove a corn.
In surgical operations which do not exert much stress on the patient’s physiology (e.g. excision of corn or small superficial tumors, tooth extraction, cataract, vasectomy etc) it is enough to conduct blood and / or urine examination to detect diabetes and only the affected part of the body is rendered numb using ‘local anaesthesia’. But this requires good co-operation from the patient.
Although some operations take only 10-15 minutes, they do not require general anaesthesia. (e.g. correction of simple fracture, curetting, and fissure). Minor surgeries like removal of tonsils, operation for hernia or cataract or curetting of the uterus do not exert any stress on the body’s physiology. Yet some laboratory investigations are necessary to assess the body’s capacity to cope with the stress due to anaesthesia and to rule out a disease like diabetes which can cause complications in any surgery.
Anaesthesia can exert a lot of stress on the body and therefore additional pathological examinations are needed like determining the level of chemical substances in blood called creatinine, determining if kidney function is affected and knowing the blood group of the patients.
Age of patient
If the patient does not have any other health problem or symptoms, It is difficult to decide which laboratory test are needed. The advantages of various tests, their utility, the cost involved – all these have to be considered.
Past and present illnesses
If the patient had jaundice during six months prior to operation, a specific blood test- liver function test is necessary to know the condition of liver function. The same is true for kidneys.
In case the patient is suffering from high or low blood pressure, certain test are done to understand theconsequences of it during operation. If the person is obese, alcoholic, smoker or has any genetic disorders, certain test are also needed.
Are all these tests essential ?
Although dozens of test are available in medical science, only the essential ones have been given here.
These have the maximum statistical possibility of elucidating adequate information in comparison with expenditure involved. These are of a generalized nature and can sometimes vary according to the nature of surgery and patient’s condition
Which operations are risky or difficult?
The risk during surgery depends upon the type and sensitivity of the illness and patient’s health. Major, emergency surgeries are risky. E.g. operation for twisted or perforated intestines. However well-planned heart and brain operations have also become comparatively safe.
As a rule of thumb, surgery is done only when the probable operative risks are less than the probable risks of not doing that operation. (i.e. risk due to illness it self ). However, one should always remember that any surgery has an element of unknown and unexpected risk.
What is anesthesia?
What are the different types of anaesthesia?
The ‘anaesthesia’ means loss of sensation. But the term is commonly used to mean loss of consciousness. Whenever any operation is being performed it involves cutting or stretching of the tissues of the body, which would cause pain. So it is necessary to provide some form of pain relief. For very small surgeries like removal of sebaceous cyst etc. the surgeon can give injection of local anesthetics at the site and make it numb. But for most of the other surgeries providing pain relief involves use of specialized techniques and potent medicines and it is the job of skilled postgraduate doctor in anaesthesia. There are three main types of anaesthesia: general, regional and monitored anaesthesia care.
In this the person is temporarily made unconscious so that no pain is perceived from the entire body. It is a carefully balanced combination of both inhaled and intravenously injected agents, which can be used for all operations.
This can only be used for surgery on selected regions of the body. An injection of local anaesthetic medication adjacent to large groups of nerves temporarily prevents pain signals from reaching the brain. For example for surgery of hip, prostate, or removal of uterus, spinal or epidural anaesthesia can be used.
Monitored Anaesthesia Care With Sedation :
This is also called as standby anaesthesia. It means that a local anaesthesia is administered and the anaesthetist gives sedatives, pain killers, and other medications while also monitoring patient’s vital signs. Cataract surgery, for example, is frequently performed with this type of anaesthesia. Before determining the most appropriate anaesthetic plan, the anaesthesiologist reviews patient’s medical condition, type and duration of operation and preferences.
Patients will meet and talk with the anaesthesiologist during the preanaesthesia check up. This check up can be few days before surgery if patient are admitted in hospital or on the day of patients admission. If patient has significant medical problems bring these problems to the attention of surgeon well in advance.
Spinal / epidural anaesthesia General information :
Of the variety of operations performed a major percentage involves operations below the waist. All these operation can be safely done under spinal or epidural anaesthesia.
The technique involves injection of local anaesthetic medicine at appropriate site to block the nerves, as they exit the spinal cord. This prevents the pain sensation due to surgery from reaching the brain & relaxes the muscles of the area making it easy for the surgeon to operate.
Procedure of spinal anaesthesia :
Once in the operation theater the saline drip is started & blood pressure is measured. Other monitors are connected if necessary. The position for giving injection can be sitting or curled up on one side depending on the choice of anaesthesiologist. The area of the injection is cleaned using antiseptic solution. The local anaesthetic is injected at the appropriate location. Initially there is tingling and numbness which is gradually replaced by complete loss of sensation of lower limb & sometimes lower abdomen.
Sedation is given to make the person comfortable unless the person wants to stay awake.
Epidural anaesthesia :
In epidural, all the initial steps are similar except that the needle remains in a superficial plane. Through the needle a very fine catheter is passed into that plane & injections of local anaesthetic are given through it. This way the anaesthesia can be prolonged by giving the doses of medicines through the catheter for as is long as desired.
After the surgery is over, the sensations & the power in the lower limbs returns back to normal within few hours.
Side effects :
The only side effect of these techniques is possibility of headache in an occasional patient. However it is self-limiting & can be managed with pain killers. The remaining side effects are exceedingly rare. It has been conclusively proved that spinal or epidural does not cause long term backache.
The advantages of spinal or epidural over general anaesthesia are ●
- Overall risk is less
- There is less blood loss during the surgery
- For caesarean section, the baby is less likely to remain sleepy after birth
- As less number of medicines are used the chances of side effects & drug interaction are less.
Anaesthesia tends to cause vomiting. On an empty stomach, chances of vomiting due to anaesthesia are reduced. Vomiting, when unconscious, may obstruct breathing and cause bronchitis or pneumonia. Therefore, no solid or liquids including water should be consumed at least six hours before operation.
What happens on the day of operation?
Sometimes premedication injections are given a short while before the surgery to help the person to relax. A small plastic cannula is inserted in the vein to start saline drip. In the operation theatre blood pressure is checked & if necessary monitors are connected. The anaesthetist remains with the patient throughout the procedure, adjusting doses of drugs as needed.
What care should be taken just after surgery?
A patient is taken out of the operation theatre only after confirmation of the normal functioning of the heart and lungs.
- Periodic examination of pulse and blood pressure is done depending upon the nature of surgery. The following are to be observed.
- Patients having nausea should be made to sleep on the sides and not flat on the back to prevent vomit from entering the wind pipe. At least the head should be positioned sideways. A tube is placed in the mouth to prevent the patient from swallowing his/her tongue. The tube should not be removed till the patient becomes conscious.
- The patient does take time to fully recover from anaesthesia. One should not panic if the patient groans in his/her sleep.
- When a patient is given an intravenous saline drip, the hand or leg through which the injection needle is inserted is not allowed to be moved so as to prevent the dislodging of the needle and the consequent piercing of the vein.
- After a major operation, when the patient recovers from anaesthesia, he / she is advised to move legs. This should be complied with as such movements prevent the possible formation of clots in the blood vessels in the calf muscles.
- A patient who is given general anaesthesia for a longer duration is advised to take deep breaths periodically. This helps to circulate fresh air throughout the lungs which is necessary to reduce the risk of lung infections.
Why should nothing be given to the patient by mouth for some time after operation?
The reason is to avoid vomiting and related problems as explained earlier. However, if there is excessive dryness in the mouth, mere moistening of lips is helpful. In case of abdominal surgeries, this period of “fasting” extends a bit longer. This is because even mere handling or manipulation of intestines stops its usual involuntary contractile movements for some time. If it is a surgery of intestine, it takes still longer. Passing of gas or stools is taken as an indication of restoration of these intestinal movements
Why and how much of saline or glucose is given intravenously?
This is done to fulfil the patient’s daily requirement of water after the operation, when oral intake is not allowed for a variable period which is from a few hours to a few days, depending upon the surgery. Four to six bottles are required for an adult in a day. The amount of saline or fluids containing other salts, to be given depends upon the type of surgery and anaesthesia, patient’s condition, frequency of vomiting and prevailing climatic condition.
What care should be taken to avoid stress on the stitches of the wound?
Several misconceptions exist regarding stitches. The number of stitches is not important. What is important is the type of surgical problem and the organ operated upon. Secondly, normal limited movements do not snap the stitching. On the other hand, such movements help the healing process, reduces toughness and sourness of the wound and pain. It is not always necessary to stay in the hospital till the stitches are removed. When other bodily functions are restored and post-operative problems (such as bleeding) are not present, the patient can go home. It depends upon the type of surgery, patient’s health condition, other facilities and cleanliness at home, etc. It is advisable to take rest at home. An increased intake of lentils or “dal” is helpful. Unnecessary costly tonics do not hasten recovery or strength. It is wrong to think that some types of food items cause pus in the operation wound.
How long does it take for the wound to heal after an operation?
If there are no complications, the wound heals within 7-8 days. It takes almost six months for the damaged muscles to become perfectly normal. Although there is no danger in doing simple, limited, normal movements, lifting of weights and the like should be avoided for 4 weeks.
What is Curetting?
To scrape carefully, the inner most lining (endometrium) of uterus is curetting.
A spoon-like instrument called ‘curette’ is used for this process, and so the word ‘curetting’.
According to people curetting is to remove unwanted pregnancy or to complete the incomplete abortion. In layman’s terms, curetting is “ to wash (clean) the uterus” but this is not a good word. Actually there is no process like washing. Monthly menses is a normal process in woman’s life and there is nothing unhygienic about it, as uneducated people think. The wrong meaning of the word curetting must have evolved form this misconcept.
Curetting is a minor operation in Obstetrics and Gynecology. If it is done carefully for the right purpose or indication, then it is beneficial in many ways. At the same time, if it is done carelessly or unnecessarily, then it may prove harmful.
Why is curetting done ? Curetting is done for diagnosing and treating some diseases of female genital tract.
For Diagnosis :
This operation is done for diagnosing the following diseases of female genital system:
1) Complaints about menses (irregularity, heavy flow, early stoppage of menses, delayed periods). Curetting is done to diagnose the cause of irregularity of menses. If the scraped endometrium is viewed under microscope, then it is possible to comment on the effect of the hormones produced by ovaries on the endometrium.
2) While investigating for infertility, if sperms of the husband are normal, then we have to look for the maturity of the egg formed in ovary (ovulation). Until now, that was assessed by curetting only. But now-adays we can know the maturity of the egg (graafian follicle) by measuring the levels of the hormone ‘Progesterone’ in the blood and also by sonography. Still curetting is done if above two tests are not available.
3) Just before menopause, some females complain of heavy flow. Whether that is because of hormonal imbalance or a warning of early cancer is exactly differentiated by curetting. Tuberculosis and cancer of uterus are diagnosed by curetting.
Curetting is done as treatment of some diseases of uterus :
1) Curetting is done for diagnosing the cause of heavy flow. In about 30-40% of females this disease is cured. Though the scientific reason behind its cure is not known, curetting is done as it has proved to be beneficial.
2) While inserting the curette the mouth of the uterus needs to be temporarily dilated. In medical terms curetting is called Dilatation and Curettage i.e. : D & C. In certain situations only the cervix needs to be dilated, e.g. when uterus is filled with pus or when radium rods need to be kept in uterus as a treatment of cancer.
3) It is also done to complete the incomplete abortion, by removing remaining products of conception from uterus.
We have seen when and why curetting is really needed. So, curetting done for ‘white discharge’ or for pain in abdomen’ is totally wrong. Only when it is done for the proper indication it proves beneficial to the patient.
How is curetting done ?
This operation can be done by anesthetizing (local anesthesia) only the cervix (mouth of uterus). But patient receives some pain in this procedure and full cooperation to the operating doctor, without any movement is not possible. For totally painless operation, General anaesthesia is needed.
After giving Local or General Anaesthesia, a rod called dilator is inserted through the cervix for dilatation. Then curette is inserted to scrape the endometrium. If it is done for diagnostic purpose, the scraped material is sent to the pathologist. The whole operation requires only 5-10 minutes.
This operation needs to be done 1-2 days before the menses in cases of menstrual irregularity, early stoppage of menses, infertility. It is done to know the effect of hormones produced by ovary on the endometrium. If done after 24 hours of commencement of menses, it is not useful as the endometrium is already shed off. It is important to carry out curetting as above-mentioned period for menstrual irregularity and infertility.
Is there any complication of the operation?
Because of the progress in anesthesiology and medical sciences, dangers in this operation are markedly reduced. Still this operation has to be done by skilled doctor and with great care. If instructions given under precautions to be followed before and after operation are followed then complication rate will be still decreased.
Complications occurring during and after the operation :
1) Uterus may get infected and fallopian tubes which carry eggs may get blocked resulting in infertility.
2) In rare situation when endometrium is scrapped more 8 than required or when curetting is done frequently, endometrium is fully destroyed resulting in Ashermann’s Syndrome. Here menses totally stop or they are scanty. This leads to infertility.
3) While dilating cervix, it may get injured. If done frequently cervix may become loose and subsequent pregnancy may end up in abortion or preterm labour.
4) Repeated to and fro movements of curette during this operation may perforate the uterus and injure structures surrounding it. In that case abdomen needs to be opened to take care of the injuries.
If the operation is done carefully, the rate of above mentioned complications is decreased markedly but still life threatening complication can occur in a very rare situation.
Quick review of how pregnancy occurs....
A woman ovulates once a month between 10th to 14th day from the start of her last period if her cycle has 28-30 days length. The ovum travels down a fallopian tube and waits for 12 to 24 hrs. Sperms travel up past the cervix to travel through uterus to the fallopian tubes. There it may combine with ovum to make an embryo. For conception this step is essential. The tiny embryo travels down into the uterus and attaches to the lining of the uterus. The embryo then grows and matures into a baby.
What is infertility? Is infertility a woman’s problem ? Infertility is usually defined as not being able to get pregnant despite trying for one year. A broader view of infertility includes not being able to carry a pregnancy to term and have a baby. Infertility affects about 10 percent of the reproductive age population,
It is a myth that infertility is always a “woman’s problem.” About one third of infertility cases are due to male factor and one third are due to female factor. Other cases are due to a combination of male and female factors or to unknown causes.
What causes infertility in men? Infertility in men is often caused by difficulties with quantity and quality of sperm or getting the sperm to reach the egg. Problems with sperm may exist from birth or develop later in life due to illness or injury. Some men produce no sperm, or produce too few sperm and few have many abnormal sperms. Lifestyle can influence the number and quality of a man’s sperm. Alcohol, smoking and drugs can temporarily reduce sperm quality. Environmental toxins, including pesticides and lead, may cause some cases of infertility in men.
What causes infertility in women? Defects with ovulation account for most infertility in women. Without ovulation, eggs are not available to be fertilized. Signs of these with ovulation include irregular menstrual periods or no periods. Simple lifestyle factors - including stress, diet, or athletic training - can affect a woman’s hormonal balance. Much less often, a hormonal imbalance from a serious medical entity such as a pituitary gland tumor can cause ovulation problems. Regardless of the cause of these hormonal imbalances, the end result may be infertility.
Aging is an important factor in female infertility. The ability of a woman’s ovaries to produce eggs declines with age, especially after age 35. About one third of couples where the woman is over 35 will have problems with fertility. By the time she reaches menopause, when her monthly periods stop for good, a woman can no longer produce eggs or become pregnant on her own. Infertility of this sort may be treated through the use of donor eggs.
Other factors can also lead to infertility in women. If the fallopian tubes are blocked at one or both ends, the egg can’t travel through the tubes into the uterus. Blocked tubes may result from pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy.
What are the essential tests done to see for the reason for the infertility ? If you are over 35, one should not wait for one year of trying before seeing a doctor. A medical evaluation begins with physical exams and medical and sexual histories of both partners. If there is no obvious problem, like improperly timed intercourse or absence of ovulation, tests may be needed to help determine the cause of the couple’s infertility.
For a man this begins with tests of his semen to look at the number, shape, and movement of his sperm. Sometimes other kinds of tests, such as hormone tests, are done to help determine if the male is a contributing factor in the couple’s infertility.
For a woman, the first step in testing is to find out if she is ovulating each month. There are several ways to do this. For example, she can keep track of changes in her morning body temperature and in the texture of her cervical mucus. Another tool is a home ovulation test kit, which can be bought at drug or grocery stores.
Checks of ovulation can also be done in the doctor’s office, using blood tests for hormone levels or ultrasound tests of the ovaries. If the woman is ovulating, more tests will need to be done to determine what contribution she is making to the couple’s infertility.
- Hysterosalpingogram HSG : An examination of the fallopian tubes and uterus after they are injected with dye. It shows if the tubes are open and shows the shape of the uterus.
- * Laparoscopy : An exam of the tubes and other female organs for disease. An instrument called a laparoscope is used to see inside the abdomen.
What is the treatment for infertility ? Depending on the test results, different treatments can be suggested. Eighty-five to 90 percent of infertility cases are treated with drugs or surgery. Various fertility drugs may be used for women with ovulation problems. It is important to talk with your health care provider about the drug to be used. You should understand the drug’s benefits and side effects. Depending on the type of fertility drug and the dosage of the drug used, multiple births (such as twins) can occur in some women. If needed, surgery can be done to repair damage to a woman’s ovaries, fallopian tubes, or uterus. Sometimes a man has an infertility problem that can be corrected by surgery.
What is assisted reproductive technology (ART) ? Assisted reproductive technology (ART) uses special methods to help infertile couples. ART involves handling both the woman’s eggs and the man’s sperm. Success rates vary and depend on many factors. ART can be expensive and time-consuming. But ART has made it possible for many couples to have children that otherwise would not have been conceived.
*In vitro fertilization (IVF) is a procedure made famous with the 1978 birth of Louise Brown, the world’s first “test tube baby.” IVF is often used when a woman’s fallopian tubes are blocked or when a man has low sperm counts. A drug is used to stimulate the ovaries to produce multiple eggs. Once mature, the eggs are removed and placed in a culture dish with the man’s sperm for fertilization. After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into cells. These fertilized are then introduced inside the uterine cavity.
ART procedures sometimes involve the use of donor eggs (eggs from another woman) or previously frozen embryos. Donor eggs may be used if a woman has impaired ovaries or has a genetic disease that could be passed on to her baby.
What should the uterine lining be at ovulation and at implantation ?
Ideally between 8 and 12 mm this should have a triple line pattern around the time of the LH surge and ovulation. The triple line occurs in response to estradiol; the HH/IE conversion is in response to progesterone.
How do we know if the sperm count is adequate for IUI ?
Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination are important to know. If the functional sperm count (number with normal morphology and rapid forward-progressive motility) exceeds 1 million; chances for pregnancy with well-timed IUI are excellent. See Semen Analysis fact sheet for more information.
What about leftover cysts in the ovaries. What causes these cysts?
A corpus luteum, or functional cyst, is simply a leftover follicle that has outstayed its welcome. Some continue to produce progesterone and estrogen, which may delay the arrival of the next period.
Do they go away?
Functional cysts almost always go away with time. Birth Control Pills are sometimes prescribed to hasten their resolution.
Why do they reduce chances of pregnancy ?
Research has shown that any cyst 10 mm or larger is associated with a lower chance of getting pregnant. Cysts do not eliminate the possibility of pregnancy in a cycle, but they do reduce it. They do this through two mechanisms. First, physically, they can crowd out the development of new follicles. Also, if the cyst is secreting hormones at the wrong time of the cycle, (for example, progesterone during the follicular phase), it interferes with the chemical balance required for good quality ovulation and drastically reduces the chances of pregnancy.
What exactly is an endometrial biopsy ?
In an endometrial biopsy (EMB), a small curette is threaded into the uterus and a sample is taken of the lining, or endometrium, during the last week of your cycle. Once the sample is obtained, it is rated according to the day of a 28- day cycle for which it would be typical. An out-of-phase endometrium means that the endometrial appearance is typical of a time in the cycle other than the time it was taken. This biopsy does have the potential to disrupt a pregnancy in progress. An EMB may also be done to check for abnormal cells in the endometrium (hyperplasia). This is a concern when a woman has very infrequent periods or when ultrasound reveals a thick lining. For this purpose, the EMB can be done on any cycle day.
How long should pt use tabs before moving to Injectables/IUI ?
The vast majority of pregnancies occur during the first 4-5 ovulatory cycles.. (Also, if you do not stimulate well on tab at a reasonably high dosage, you might consider moving on to Injectables earlier. The maximum dosage is 150 mg., according to the manufacturer, and it may be wise to move on if unsuccessful after two cycles at that dosage). The average number of cycles on tabs before moving on is three to six.
How many times should anyone try IUI before moving on to IVF ?
Once a patient has had 3-6 IUI cycles with injectables, they might consider moving to IVF as the chance of a successful IUI cycle is reduced.
What is the maximum recommended dosage for tab (clomiphene citrate) ?
As mentioned about, the maximum dosage is 150 according to manufactures. It may be wise to move on if there is no response to 150 mg, as the risk of antiestrogenic side effects of Clomiphene citrate increase sharply as the dosage goes up.
How should IUIs be timed ?
In most cases, doctors who do two IUI’s do the first about 24 hours after the HCG shot and the second about 48 hours after the shot. Some studies have shown that doing one IUI about 36 hours after the HCG is equally effective. However, some recent research suggests that higher pregnancy rates may be achieved by doing two IUI’s, one at 12 hours past the HCG shot and one at 34 hours. 11
What are the logistics of injectables ?
Typically, they are taken daily for 7-12 days (although it is possible to take them as long as 14 days). If you are taking subcutaneous injections, they are administered in the stomach, upper arm or thigh, with a 1/2- or 5/8 inch needle. If they are intramuscular, they are given in the hip/buttocks area using a 1.5 inch needle. The partner usually administers the IM shots. You can also give the IM injection to yourself in the thigh. They feel like a flu shot or vaccine.
Should I use a BBT chart ?
A Basal Body Temperature chart is not a very reliable way to predict ovulation. Although the temperature shift associated with ovulation can be detected on a basal thermometer, it can sometimes take as long as two days before this shift shows up on a BBT. This generally means that by the time a temperature shift is detected, it is too late to time intercourse effectively. Further, there are many things that can negatively affect the reliability of BBT monitoring: A change in sleep patterns, getting up to go to the bathroom in the night, a cold or flu, etc., can all change the results.
Multiple cycles with fertility drugs increase the chance of getting ovarian cancer. Is this true?
No. There is no evidence that shows a statistically significant increase in the ovarian cancer risk.
Do your chances increase with each consecutive cycle?
No, each cycle is independent. Your per-cycle chances do not increase.
What is ovarian hyperstimulation.
OHSS (Ovarian Hyperstimulation Syndrome) is when you have an unusually large number of mature follicles that release. When these follicles release, there is an unusually high concentration of estrogen-rich fluid in the peritoneal cavity, and the ovaries are generally enlarged far beyond their usual plum size - in some cases, they can swell to softball size The best pre-ovulation predictor of hyperstimulation is the E2 level, but it is not a perfect predictor. If you experience symptoms of OHSS, you should always play it safe and check with your doctor.
What do you mean by poor egg quality.
You can get somewhat of an idea from the size of the egg and the estradiol level at midcycle. But other factors arise as you get further into your 30s, such as whether the outside covering is too thick to be penetrated easily by the sperm. You really can’t diagnose egg quality until you get the eggs out of the follicles, put them under the microscope, and see how they behave. There are some less invasive screenings for ovarian reserve/egg quality such as the Clomiphene challenge, FSH, and Inhibin B, but they are also not as accurate as looking at the egg directly.
What causes chemical pregnancies ?
Many early pregnancy failures are due to genetic abnormalities, mainly “trisomies” where an extra chromosome is present in what should be a pair. Some pathologists believe that the earlier the failure occurs after implantation, the more likely it is to be genetic. You can also have implantation problems that would cause chemical pregnancies such as hypercoagulation, failure to form the needed blood vessels, or autoimmune issues. Note that chemical pregnancies are early miscarriages.
Birth of a baby is one of the most joyous moment in a woman’s life. To have this joy, the labouring woman has to undergo a long journey, which is full of pain. The pain varies in intensity from person to person. Textbooks have described this pain as “worse than pain of a fracture”!
Various methods have been used in the past to alleviate the pain. These range from psychotherapy to massages to various drugs. These have been practiced since ages & various reports have claimed that their method is the best.
Why does labour cause pain ?
Once the process of labour begins, the uterus tries to push the baby downwards to the pelvis and tries to expel the baby out. The uterine muscle contracts & relaxes resulting in pushing the baby down. These contractions like a vigorous exercise are responsible for pain.
How severe is the pain ?
Pain experienced during labour is mild initially. It slowly increases in intensity, frequency and severity as time passes. The intensity of pain is much more in anxious patients and in primi gravidas. (Women delivering for the first time)
Is pain useful ?
The intensity of pain enables to know how the labour process is progressing. However, at a point, the pain becomes a suffering than an indicator of onset and progress of labour. Pain itself has deleterious effects on mother and baby.
Will the labour progress if there is no pain ?
The common misbelief with labour analgesia is that if the labouring woman doesn’t get pain, how will she progress towards normal delivery. Pain reducing techniques block the pain produced by uterine contractions. They do not reduce intensity & frequency of contractions. Thus, it does not have bad effect on progress of labour.
What can be done to reduce the pain ?
Various methods can be adopted to reduce intensity of pain.
– Education of patient & counseling also plays important role in pain management as the patient understands & expects a certain amount of pain.
– Drugs: drugs like morphine, pentazocine by intravenous route have been & are being used to reduce pain.
– Gentle back massage is also helpful in relieving pain to a certain extent. – Breathing gases like Entonox are quite popular in the western countries & are extensively used. These increase pain tolerance.
– Stimulating certain skin areas with mild electrical current is also useful for pain relief.
– Epidural analgesia is the most commonly administered modality to get relief from pain during labour.
What is epidural analgesia ?
Epidural analgesia is a technique in which local anaesthetic agent is placed around the nerves supplying the uterus & birth canal. It thus stops the pain associated with contractions, dilatation of cervix and distension of birth canal. The patient is still aware of contractions of the uterus. Patient is awake & in control of labour as the drugs used for the technique has no sedating effect on the mother & baby.
Who will do it ?
A qualified anaesthetist specialized n the technique of labour analgesia will do the procedure of insertion of catheter and will be with you in the labour ward till you deliver. Pain relieving injections will be given as per your demand.
Prerequisites for Epidural analgesia
Detail history is taken & examination carried out by anaesthetist to rule out risk factors if any. Anaesthetist may ask for certain blood test if required. Consent is taken. Procedure is explained to the patient.
When can I have Epidural or Spinal Analgesia ?
You should discuss your wishes about labor analgesia with your obstetrician or anaesthetist during your prenatal care. Spinal or Epidural analgesia is easier to start before labor discomfort makes it difficult for you to discuss your situation or cooperate in analgesia administration. However, you may let the labor nurse and your physician know if you are interested in having Epidural or Spinal analgesia at any point in your labor.
When you can actually receive the analgesia depends on circumstances surrounding your labor pattern and assessment by your physician. At the appropriate time, an anesthesiologist will discuss the techniques with you and suggest options in accordance with your wishes and those of your physician. You may have concerns unique to you that your anesthesiologist will need to discuss, and you should have an opportunity to ask questions. If you and your anesthesiologist agree after this discussion, preparations will be made to administer an analgesic. Although it is unlikely, an anesthesiologist may not be immediately available to administer the analgesia because of emergencies; or there might be a reason that makes if inadvisable for you to have Epidural or Spinal analgesia.
How is epidural catheter put in ?
Catheter insertion procedure is done in sitting position or lying down on one side. Patient is asked to remain still during the procedure so as to avoid inadvertent injury. It is easier to put in epidural catheter when the contractions are not too painful but it is never too late to ask for one.
The anaesthetist will clean your back using antiseptic solutions. Small amount of local anaesthetic agent is injected into the area where the catheter will be inserted. A special large needle will be used to determine epidural space. (It is a space above the dura, which covers the spinal cord.) A very fine polythene tube is inserted in this epidural space through the needle. The needle is then removed. The tube is left in place and firmly fixed to the back. Local anesthetic & other pain relieving drugs are given through this tube for analgesia whenever the patient demands. It takes about 15 – 30 minutes for maximum pain relief.
What can I expect from Epidural or Spinal Analgesia?
Pain relief from Epidural or Spinal analgesia is usually more complete and intense as compared to the other forms of labor analgesia. Most women notice a pressure sensation with their contractions; this pressure sensation is an important mechanism that keeps labor progressing. With the concentrations of local anesthetics and adjuvants used for epidural analgesia labouring woman can ambulate. There is no weakness or numbness in legs.
How long will the Analgesia last ?
Continuous Epidural analgesia can usually be made to last as long as your labor lasts. Injections will be effective depending on the characteristics of the drug injected. Without the use of the catheter, they cannot be repeated without replacement of a needle. Toward the end of labor - when the birth of the baby is close at hand and discomfort is more intense - additional medication or techniques may be needed.
What happens if I need a C-Section ?
The type of anesthesia used for a C-Section will depend on the urgency and nature of the reason for the surgery. Continuous Epidural technique can be extended for use during a C-Section.
Are there any other advantages?
Apart from pain relief, epidural analgesia increases blood supply to the baby and improves its well-being. This is very important in cases where the blood supply to the baby is compromised e.g. High blood pressure in mother, Growth restricted babies etc. Epidural analgesia is known to shorten duration of labour. Studies have also shown that the caesarean delivery rate is reduced. If a patient requires emergency caesarean section, anaesthesia can be given through the same catheter without additional pricks. In case of dire emergency, the anaesthetist is always available at the very instant to undertake emergency measures.
Does the medication affect the baby ?
The doses of medication typically used in labor analgesia usually do not cause any noticeable effect in your baby’s Apgar scores or behavior. The Spinal and Epidural techniques use very small doses of medications; the local and IV techniques use larger doses. Your body will have essentially eliminated these medications before your breasts begin producing milk for breast feeding.
Are there any complications ?
Complications with epidural analgesia technique are extremely rare. Occasionally, headache can be complained by the patient, which may require treatment. Reaction to local anaesthetic is extremely rare.
Will this injection cause backache ?
Epidural analgesia is not responsible for backache. The reason for backache in a woman after delivery is laxity of ligaments, change in the curvature of back, laxity of abdominal muscles, lack of calcium in diet / supplement. These are wrongly attributed to the injection in the back. Several studies have shown that epidural analgesia does not cause backache. Epidural anesthesia or analgesia provides relief or reduction of labor pain without affecting the mother’s mental state. It enables an exhausted mother to relax or sleep during labor and calms the woman who is anxious and tense because of pain. Once an epidural catheter is in place, additional medication can easily be administered as needed, providing prolonged and consistent pain relief.
How do you know that you are pregnant ?
You may have symptoms like.
(1) Sudden cessation of otherwise normally occurring periods
(2) Nausea, vomiting
(3) Frequency of urination
(4) Heaviness in breasts
(5) Excessive fatigue
You can confirm pregnancy by pathologically testing the morning sample of urine about one week after missing your periods.
Pregnancy lasts for about 40 weeks or 9 months and 9 days from the first day of fast menstrual period. Development of the different organs of the baby occurs in the first three months. Hence you should avoid taking any sort of medicines during this period without consulting your doctor.
You will start feeling your baby’s movements by about fifth month. You will gain about 10-12 kgs during your pregnancy.
As pregnancy advances due to the growing size of the uterus you may feel breathless, tired, swelling of feet or burning in chest.
Please consult your doctor anytime you face these problems. It is advisable to consult the doctor soon after missing the menstrual period.
Some common problems in pregnancy and their solutions.
(1) Nausea, Vomiting This mainly occurs in the first 3 months of pregnancy. Eat small frequent meals Avoid oily spicy foods Drink lot of water. You may take medicines which your doctor prescribes for you. These are safe in pregnancy.
(2) Frequency of urination. This is common in the first three months and the last month of pregnancy. It is due to altered physiology in the body. Make a habit of passing urine every two hours. Drink less water before bedtime.
(3) Constipation Drink plenty of water Increase roughage and green leafy vegetables in your diet. Have regular light exercise.
(4) Burning in chest Eat small frequent meals, avoid oily spicy foods. Drink cold milk before bedtime.
(5) Bleeding piles avoid constipation. Have daily light exercise Consult your doctor.
(6) Swelling of feet Some amount of swelling of feet in last few months of pregnancy is due to pressure of enlarged uterus. But it could also be a sign of increasing blood pressure. Sleep on one side of body. Keep a pillow under your feet while sleeping. Do not stand at one place for a long time .
(7) Backache & leg - cramps - Adequate rest & calcium can alleviate these symptoms. If unbearable please consult your doctor for medication.
Pregnancy and medical check up
Medical check ups are essential to ensure that pregnancy is proceeding smoothly and to diagnose any complications at the earliest.
Please consult your doctor as soon as you realize you are pregnant.
You must visit your doctor at least monthly for first 6 months, fortnightly for next 2 months and weekly during last month.
The frequency of these visits may change at the discretion of your doctor if there are any complications.
Consult your doctor immediately if you have any time
v Pain in abdomen
v Watery discharge per vaginum
v Decrease in movements of your baby.
At every visit your doctor will check
– your blood pressure.
– your weight.
– any swelling of feet,
– if your baby is growing well.
Your doctor will check your blood and urine.
Your doctor will do your sonography by fourth or fifth month to see if your baby is completely normal & to rule our certain abnormalities.
Your doctor will start you on iron, folic acid and calcium tablets.
You will be given two injections of tetanus toxoid during your check-ups . Keep all your reports and records carefully and take them with you when you go for delivery.
Diet and care in Pregnancy
Your baby is totally dependant on you for its growth. Hence you must eat well in pregnancy.
Your diet should be complete and wholesome in carbohydrates, proteins, fats, minerals and vitamins.
You should also take iron and calcium tablets after three months and continue upto 3 months after delivery.
You should drink a glass of milk daily to increase your calcium intake. There are no specific dietary restrictions in pregnancy. Home cooked food is safer.
One should preferably avoid sexual intercourse during first 3 months of pregnancy and also after seventh month to avoid risk of abortion and preterm labour.
A pregnant woman should have minimum two hours rest in the afternoon and 8 hours sleep at night. Avoid long journey in pregnancy. While travelling try and avoid rough and bumpy roads.
Pregnancy and exercise Do only light exercise while pregnant. This helps prevent constipation, keeps body supple and also helps easy delivery. Avoid exercise during first 3 months of pregnancy. Always assume correct posture while standing or sitting. The safest & the best exercise in pregnancy is walking. You can consult your doctor about light exercises that can be done in pregnancy. Also continue exercising after delivery to regain your shape and improve the tone of your muscles.
How to know the date of your delivery ?
If a woman is having regular periods, the date of delivery is calculated by adding 7 days and giving forward nine months from the date of last M. C.
Delivery usually occurs around two weeks before or after this expected date.
How to know that your labour has started ?
1. Pain in abdomen and / or back.
The pain keeps coming and going.
The intensity & duration of pain increases.
If initially pain comes every 10-15 minutes, later they come earlier and earlier.
2. Discharge per vaginum.
It is slight and usually blood stained. This occurs from the mouth of the uterus which must have started opening.
Before going to hospital, take care of the following precautions.
– Do not eat or drink anything once you suspect the beginning of delivery process.
– always have a relative accompany you.
– Take all your reports with you. Your doctor will examine your thoroughly and decide whether you can deliver normally or you will need a caesarean section. Even if your pregnancy has proceeded smoothly and everything is normal, there are some situations where your doctor will have to do a caesarean section to deliver you.
– The first delivery usually takes 12-14 hours while later deliveries occur faster. Remove all your fears and worries and co-operate with your doctor. This will allow you to have a safe and easy delivery . Occasionally during the course of your delivery you may require a caesarean section due to some unforeseen events. You must exclusively breast feed your baby upto four months of age. Weaning should be started from fourth month. Before going home consult your doctor about different methods of family planning to protect you from having another baby soon.
Some commonly asked questions in pregnancy.
Q 1. What restrictions should be applied to diet ?
Ans. There are no special restrictions to be followed. During first 3 months if there is nausea and vomiting one should have small frequent feeds and eat dry foods like bread, biscuits in the morning. In last few months due to burning in chest avoid only spicy food.
Q 2. Does eating papaya, jackfruit cause harm ?
Ans. There is no harm if one eats such fruits in moderation
Q. 3 Are medicines safe in pregnancy .
Ans. As the baby is developing in the first 3 months, one should take medicines only after consulting one’s doctor. There is no harm with sonography. One should avoid X-rays in pregnancy and if absolutely essential, one should take out X-ray with abdominal shield.
Q. 4 Why should sleep on one side ?
Ans. It helps to increase blood supply to the uterus and baby by removing pressure of uterus on the large blood vessels.
Q. 5 Should one abstain from inter course in pregnancy ?
Ans. If one had any problems in previous pregnancy one should refrain from sexual intercourse. Otherwise one should abstain during first 3 months and after the seventh month.
Q. 6 Is eclipse harmful to the baby.
Ans. No. There is absolutely no scientific basis for this.
Q. 7 If the liquor amnii gets less then does drinking lot of water help?
Ans. Drinking water will not help to increase the liquor in the uterus.
Q. 8 Can one work on the computer when pregnant?
Ans. There is no harm, in working on the computer.
Q. 9 Can one undergo dental treatments during pregnancy.
Ans. If one informs the dentist that one is pregnant then he will take adequate precautions during treatment.
Q. 10 Will eating iron and calcium tables make the baby big and cause difficult delivery?
Ans. No. These tablets will not make your baby big as wrongly supposed.
Q. 11 Will salt restriction help if there is swelling of feet?
Ans. Salt restriction or diuretics do not help to decrease swelling of feet.
Q. 12 It is said that excess rest is not good during pregnancy?
Ans. A pregnant woman must take 2 hours rest in the afternoon and 8 hours sleep at night. This helps the baby’s growth. If a lady is feeling excess tired and sleepy one should rule out any medical problem like anaemia.
Q. 13 Should one avoid scooter driving, travelling in autorickshaw in pregnancy?
Ans. Till 7 months, there in no problem in driving scooter or going in autorickshaw if you have no medical problem. Drive slowly. Be careful while kickstarting or pulling scooter on stand, avoid rough roads. Travelling in bus is safer than travelling in autorickshaw.
Q. 14 Should one avoid journey in pregnancy?
Ans. Avoid long journeys and travelling in first 3 months. If one has to travel to maternal home for delivery then one should do so by 32-34 weeks. Travelling by aeroplane is not allowed after 32 weeks.
Q. 15 Should one take any special care of breasts in pregnancy.
Ans. One should keep breast and nipples clean during bath if nipples are retracted, daily one should pull them out. There will be some watery secretions from nipple. This is normal and no cause for concern.
Instrumental Vaginal Delivery
Though most of the patients deliver vaginally normally, few (2% to 5%) may require assistance to complete the process of delivery from below. This is done in the interest of the mother & her baby. This also avoids caesarean section in a few cases. There are basically 3 ways in which pt. can be assisted to deliver vaginally.
(1) Fundal Pressure : Criticised by few, it is one way to help the patient when she is about to deliver. Here manual pressure is given on the top of the uterus while uterus is contracting so that the patient is helped to push her baby down. It is a very gentle push, not brutal but at the same time can be very effective.
(2) Forceps : Here a pair of blades called forceps are applied around the baby’s head very gently & carefully when it is low down near introitus. Then during uterine contraction (next pain) baby is pulled down. Such 2-4 pulls may be required for a successful delivery from below. It is preformed under local anaesthesia. It is a minor but very skillful operation.
Risk : Rarely it may give rise to trauma to baby’s head / brain. Sometimes baby may take slightly longer time to cry. In mother it can give rise to extension of cut given on perineum. Rarely little extra blood -loss may take place, very rarely mouth of the uterus may be torn.
(3) Ventouse : A 4 to 6 cm. diameter small cup (plastic or metallic) is applied on the baby’s head Little amount of negative pressure is created in the cup with the help of a machine. & then pull is given in downward direction during uterine contraction. This pulls down baby’s head with least complication to mother or baby.
Risk : Small swelling on the baby’s head may develope. Very rarely bleeding in the baby’s brain may occur. Risk to the mother is rarely laceration of the the mouth of uterus. Above three procedures are all minor. All of these require small cut on the mother’s perineum called episiotomy which facilitates delivery from below.
Why one has to undertake one of these procedures to complete vaginal delivery ? a) Here doctor’s intention is to deliver the baby from below. Labour has advanced quite a lot. Mouth of the uterus is completely open. Suddenly baby’s heart activity becomes irregular or heart rate increases / decreases suddenly. This indicates that baby is suffocating inside the uterus due to lack of oxygen / nutrients. Especially when the water around the baby becomes greenish - yellow in colour which is because the baby passes meconium i.e. stools in the uterine cavity. This can be very dangerous & can create lot of problems & complications to the baby. b) It can also be performed on those mothers who are exhausted a lot during delivery. They require help / assistance from below to push down the baby. (c) In few cases passage for the delivery is small & bit narrow (minor CPD). But otherwise the labour process has advanced quite a lot & little help in one of the above forms may deliver patient from below successfully. But always remember that these are the efforts on the part of the doctor to deliver patient from below with minimal risk to mother & baby. These efforts / techniques may fail sometimes & patient may require caesarean section.
What exactly is caesarean section ? (C.S.)
When the baby is delivered by taking a cut on mother’s abdomen & the uterus, it is said to be delivered by C.S. The history of this surgery is quite interesting, though there is dispute about it’s origin amongst the historians. It is said that the Roman King-Julieus Caesar was delivered by this unnatural route & hence the name C. S.
Indications of C. S. - In what conditions do we do CS ?
The frequency of use of this technique of delivery has increased due to newer research in obstetrics. Generally, whenever the natural delivery may be disadvantageous or hazardous to mother &/or baby, this route of CS is preferred. Let us review some of the important situations where CS is done-
(1) Contracted bony passage -(Contracted Pelvis) In ladies shorter than 5' in height, the pelvis i.e. the bony passage of delivery is likely to be small and hence CS has to be done. In India, especially in rural areas, early marriages lead to teenage pregnancies. The pelvic bones have not grown to their full capacity & hence the bony birth passage is contracted. 2) Genital Tumors- The tumors obstruct the birth passage due to their bulk & position & hence CS has to be done. 3) Two or more than two previous CS - In such cases, there is risk of the uterine scar getting weaker & sometimes rupture uterus is a possibility. 4) Maternal diseases - Severe pregnancy induced hypertension, Eclampsia, Diabetes, Cancer of cervix. In these conditions, CS is done, to reduce maternal & fetal risks. 5) Placenta at the OS- Placenta previa. In this condition, the mother can bleed dangerously if CS is not done timely. 6) Accidental hemorrhage- In this condition, the placenta separates from its position & blood clots accumulate in the uterus which has bad effects on coagulation mechanism in the body. In such cases timely CS can save mother & baby. 7) Genital Herpes & HIV infections. In this maternal viral infection, natural delivery proves hazardous to the baby & hence CS is done.
Causes relating to the baby
1) Fetal distress- The baby gets less blood supply & hence gives signals of getting asphyxiated in the uterus, -egirregular / slow heart sounds, passing motion in the uterus. In such cases the fastest way to save the baby from the in utero insult is CS. 2) Cord prolapse - The cord simply comes out from the OS before the baby & the blood supply to the baby gets hampered & hence CS is must. 3) Intrauterine growth retardation - If the baby is severely growth retarded, it can not withstand the labour pains. 4) Transverse lie with or without hand prolapse/breech presentation- In both these conditions, the baby does not present in the normal position i.e. head in the pelvis & buttocks in the fundus of the uterus. These are called malpresentations which necessitate the use of CS. 5) Bad obstetric history-in some cases, there is history of repeated abortions/fetal loss & there is no living issue, the mother may also be elderly in such cases, CS is a safe alternative.
Other Indications : Sometimes natural delivery becomes unsafe for both mother & the baby -eg- (1) Prolonged leaking - in this case the bag of waters ruptures early & may lead to maternal as well as fetal infection, CS can prevent this risk (2) Failed forceps Sometimes forceps application may not result in delivery of the baby & hence immediate CS is resorted to. There may be more than one causes or indications for doing CS in a single case & hence CS is mainly done to safeguard both-mother & baby.
Why is CS done as emergency, in spite of anticipating normal delivery ?
Many a times, the doctor tells the patient that she will deliver normally, but she has to undergo an emergency CS. Why does this happen? During antenatal check-ups & at USG exams it is not possible to diagnose cord round neck or true knot in the cord. Babies with such complications start getting heart rate variations during labour & hence emergency CS has to be done. Post maturity, decrease in the quantity of liquor, are also some examples where CS has to be done. Delivery is a dynamic process exerting lot of stress on the mother & the baby. Many unexpected problems may crop up & endanger the life of -ne baby &/or mother. At the time of emergency CS, the relatives need to comply & cc-operate with the doctor so that the CS is done as early as possible to save the baby. Many important things like booking the blood for the patient, calling the anaesthetist immediately have to be done within very limited time.
Anaesthesia for CS
CS can be done under general anaesthesia or spinal anaesthesia - in which the part below the abdomen is anesthetized by giving injection in spinal fluid at a particular site. Now a days, epidural anaesthesia used for painless labour can also be given for CS. Rarely, CS has to be done under local anaesthesiaThe obstetrician and the anaesthetist decide the type of anaesthesia suitable for a particular case according to maternal / fetal condition. The best suitable anaesthesia is chosen which will not do any harm / side effects to mother & or baby.
How is this operation done ?
After giving the suitable anaesthesia, a cut is taken below the umbilicus vertically, or transversely on the lower abdomen. The urinary bladder is pushed down and the uterus is incised transversely. The baby & placenta is delivered & the cut structures are sutured in place as they were before. Generally, the operation requires about one to one & a half hour.
Is blood transfusion must at every CS ?
As we do for any other major surgery, it is always better to keep blood ready, booked in the blood bank, through most of the times BT is not required. Blood Transfusion is mainly required when the mother is already anaemic &/or she bleeds more at the time of C. S. BT has to be given as a life saving measure in cases of uncontrollable, severe postpartum bleeding, (when the uterus does not contract)
What preoperative preparations are done before CS ?
For a planned CS, it is possible to take all preoperative measures but in an emergency case, we may have to make some changes. (1) Nil by mouth - At least for six hours before CS no water / food is given to the patient by mouth. This may not always be applicable at emergency CS. 2) Shaving of abdomen is done and the skin is cleaned with antiseptic lotions & liquids. Pre operative antibiotics also may be started. 3) Enema is given to evacuate the bowel. 4) The relevant information about CS & its risks are explained to the patient & written consent of the patient & relatives is taken. 5) Whenever possible The neonatologist is called in advance to take care of the new born at CS.
What care is taken after the operation ?
(1) After the operation, I. V. fluids is given for about 12 to 24 hours. Intra-venous antibiotics are given to prevent infection. Analgesics are used to lessen the postoperative pain. (2) Water & food is given to the patient only after the doctor advises to do so. (3) The patients pulse, BP, temperature, the abdomen, presence / absence of bleeding is checked periodically. (4) In spite of some pain, it is better to get up in bed, walk to the toilet & breast feed the baby as early as possible, with the help of the hospital staff. (5) The patient can breast feed the baby even if intravenous fluids are going on. (6) Generally, stitches are removed on 5TH to 8TH day & if the wound is dry, she is discharged home.
What care has to be taken at home after discharge ?
The patient can take bath, if the wound is healthy. The wound must be washed with water and mopped dry with soft clean cloth. The scabs should not be removed, they will fall off on their own. Some amount of itching sensation at the site of wound is normal but scratching should be avoided. Antiseptic ointments may be applied as per doctor’s advice. It is not advisable to apply oil or talcum powder on the wound. The diet of the patient should be a balanced diet. The tablets of iron & calcium should be taken at least till breast feeding is on. The inner wound in the abdomen takes about 1 1/2 months to heal completely & hence any work causing tension on abdominal wall should be avoided -eg- lifting of heavy objects should not be done. Post - partum exercises can be done under doctor’s supervision & advise.
What about contraception after CS ?
At the time of third CS, tubectomy i.e. sterilization operation can be done at the time of doing CS itself. Vasectomy - i.e. male sterilization can be done if patient has undergone 2 or more CS. Copper T can be put in after one CS at 6 weeks after CS. Oral contraceptive pills, injections & other mechanical devices can also be used according to doctors advise.
Why should next pregnancy be spaced at least 2 years after the CS ?
To avoid physical and mental burden on the mother next pregnancy should be spaced adequately i.e. at least for 2 years. If next pregnancy occurs earlier than this period, the wound on the uterus remains weak & may still weaken at next pregnancy. The scar on abdomen also gets weaker and incisional hernia may become a bothersome problem.
What are the risks of CS operations ?
CS is a major operation & entails some risks, which can be prevented to some extent. The examples of risks are - profuse bleeding at or after the operation, hypotension, injury to urinary bladder or other nearby organs, infection. Rarely, the matter in the fluid around the baby passes in mother’s blood vessels leading to a dangerous condition called amniotic fluid embolism. There are some anaesthetic complications also but due to good & effective drugs & good techniques of operations & anaesthesia, the risks have been minimised today.
What care should be taken in next pregnancy ?
As soon as the patient knows that she is pregnant, she should get examined by the doctor as early as possible. Sometimes, especially in rural & uneducated class of patients, the antenatal check ups are purposefully avoided & the patient is taken to the hospital directly when she goes in labour. This can prove dangerous for the patient. 20
Is normal delivery possible after C. S. ?
If the previous CS has been done for a non-repetitive cause then next time, normal delivery is possible.
Why has the incidence of CS operation increased today ?
Today, every pregnancy is a very precious pregnancy. The picture of olden times - large number of pregnancies with some neonatal / infant deaths is no more seen. Every pregnancy must end up in safe delivery & a healthy baby is the motto of today’s society. CS operation has become a much safer operation than in olden times due to progress in subjects of anaesthesia, surgical techniques & medicine in general. Hence even if natural delivery entails any minimum risk to mother &/or baby, CS is resorted to. Now-a-days, it is seen that some of the pregnant ladies do not like or want to undergo painful labour & hence there is a demand from such patients for CS & the doctor is really pressurised to do so. The relatives also become anxious & repeatedly question the obstetrician about the possibility of CS. The decision of doing CS. Should be left to doctor’s acumen. In some cases, CS may have to be done due to such social pressure. For this, the patients need to be educated about the process of labour & how the patient can co-operate leading to a normal delivery. This can really prevent some of the unnecessary CS. Though the risks of CS have been minimised today, it is ultimately a major operation & it does entail some unexpected & unanticipated risks. Doctor-patient communication- Many a times, the relatives & the patient have a doubt in mind about whether the CS is really necessary. The CS is being done to earn money and is being done unnecessarily & in spite of normal delivery being possible is one of the thoughts always present in their minds. For this the patient must be communicated in a very convincing & scientific way, the reason for doing CS. In. case the patient asks for, the doctor should be open enough to call another doctor for opinion. In “high-risk” cases eg-B.O.H., diabetes, twins, previous CS, the doctor has to take tremendous risk to conduct a normal delivery. In fact, conducting a normal delivery for such patients is more difficult, demanding & time consuming for the doctor, it is a great mental tension for him too. In such cases, the fees charged the doctor for normal delivery & CS should be about the same amount so that “money - earning” factor may be wiped off from the patients mind. During frequent antenatal visits the doctor should develop go communication with the patient & her relatives. Some information about CS whether CS is anticipated in her case & why may be communicated to her during her visits so that indicated CS are really done & unnecessary CS are avoided.
Epidural Analgesia For Labour
The fear of pain of childbirth haunts every expectant mother almost from the time she gets pregnant. For years women have been tolerating this suffering; mainly because it being a natural process, it is thought better, not to interfere with it. Also it is felt that birth of the baby, being a pleasant ending will make her forget the suffering. A prolonged and painful process of childbirth can have adverse effects on the mother and the unborn baby, hence attempts to reduce this pain date back centuries. Since no safe and completely acceptable method was available, pain relief in labour remained a myth; till recent years when epidural analgesia emerged as the most widely accepted safe choice.
Why does labour cause pain ?
Once the process of delivery sets in the uterus (the bag which holds the baby) starts contracting so as to expel the baby out. These contractions like an extremely vigorous muscular exercise cause pain.
Is the pain really severe ?
Most of the times the pain is very severe and can be compared to the pain of fracture of a bone. Tolerance to pain is subjective and hence some women may be able to bear the pain while others may not. The pain and associated anxiety is more at the time of the first delivery.
Is the pain useful ?
Labour pain gives an indication to the expectant mother that the delivery process has begun. However after that it loses its usefulness and becomes a suffering.
If the pain is gone, how will the labour progress ?
With pain reducing techniques, only the pain conducting nerves are blocked, however the process of uterine contractions continues.
What are the harmful effects of pain ?
Pain leads to increase in anxiety. This leads to excessive sweating, increased heart rate, increased rate of breathing, increase in blood pressure, flushing, muscle cramps, nausea and vomiting in the mother which in turn may lead to distress of the baby within the uterus. An anxious mother or a prolonged labour thus has adverse effects.
What can be done to reduce the pain ?
Various methods have been used to - date like injecting morphine and morphine like drugs through the veins, breathing gases like Nitrous oxide, stimulating certain areas of the skin with mild electric current, meditation, acupressure, psychological natural childbirth techniques and others. The ideal method of pain relief should be one which is 1) Universally acceptable and available 2) It should give adequate pain relief throughout labour 3) It should have no side effects on the mother and the baby. It should not have any effect on the progress of labour 5) There should not be a need for special equipment and it should be affordable. All over the world the method which has proved clearly superior over the others is Epidural Analgesia.
What is Epidural Analgesia ?
In this technique a local anaesthetic is placed around the nerves that supply the uterus and the birth canal and this stops the pain associated with contractions. The woman remains aware of the contraction. She is awake and is able to experience the process of labour as a pleasurable situation.
How is it given ?
The procedure is done by an anaesthetist in either a sitting or lying on one side position.The anaesthetist cleans the back using antiseptic solutions. Local anaesthesia is given at the site of the epidural injection and the epidural space is located by means of a special needle. A very thin polythene tube (catheter) is inserted through the needle into the epidural space. The needle is then removed and the tube is left in place, by fixing it firmly onto the back using adhesive tape. Anaesthetic doses are given through the tube to relieve pain, as and when necessary. It takes about thirty minutes for maximum pain relief. It is easier to put in an epidural catheter before the contractions become too painful, but it is never too late to ask for it.
Does it have any other advantages ?
Apart from relief of pain, it increase the blood supply to the baby and improves its well being. Epidural Analgesia is also known to shorten the duration of labour. In case some emergency arises in relation to the mother or baby, the anaesthetist is available at the very instant, and the same anaesthesia can be used for caesarean section, if required.
What are the disadvantages ? Occasionally the injection can cause headache which may need treatment. Complications like reaction to the anaesthetic drug and dose related complications are rare. It has been felt over the years that since the pain sensations are blocked, delivery needs to be conducted by instrumental methods like forceps or vacuum forceps. Use of newer drugs and the right timing of the doses have shown that there is no increase in the instrumental delivery rate or caesarean section rate
Does this injection cause backache ?
No. It is statistically proved that an injection in the back is not a cause of backache. On the contrary, epidural injections are often used in the treatment of back problems. After delivery, there are many other causes of back pain like laxity of ligaments, calcium deficiency, which are wrongly attributed to the injection in the back.
What about the cost ?
Every good thing has a price. There are no fixed charges for the procedure, as it would depend upon the place where you deliver (city, district etc), the difficulty and the duration of labour and the prevalent charges of the anaesthetist.
Operation on the Appendix – Why and How
Operations on the appendix amongst the commonest and important surgeries. The appendix, an organ situated near the end of the small intestines, gets swollen and causes severe pain in the abdomen and needs to be removed by operation. Sometimes, due to misdiagnosis on part of the treating doctor or due to fear of the surgery, the operation is not performed at the appropriate time, this can endanger the patient’s life. On the other hand, there are many a Surgeons who under the guise of any abdominal pain knock off the appendix for monetary gains. To avoid this, the general public needs to be educated to some extent about this simple and common disease.
Where does the appendix lie and what is its function ?
The appendix is a wormlike appendage situated in the lower right part of the abdomen at the junction of the small and the large gut. This 1"-5" organ is present in all humans since birth. It is not an organ that is formed later on as is the common misconception. This organ plays no role either in the digestion of food nor any other function. It is a ‘vestigial’ organ.
Why does the appendix get inflamed ?
Appendicitis means swelling of the appendix. Its exact cause, though, is not known fully, but the swelling can occur due to two causes. 1) Non-obstructive: Due to infection, the whole appendix gets affected. But the swelling does not increase rapidly and many times it reduces on its own or due to the medicines given by the doctor. This can occur repeatedly. There is minimal risk of appendicular rupture. But it does result in the formation of adhesions between the bowels and the protective fatty layer resulting in the formation of a mass or lump. 2) Obstructive : Due to fecoliths or worms, the lumen of the appendix gets blocked. This results in severe swelling, which can increase rapidly and without timely surgical intervention, can result in the rupture of the appendix. This can form a localized collection of pus or the pus can disseminate all over the inside of the abdomen and can result in a very serious condition of the patient.
What are the signs and symptoms of appendicitis ?
It can affect males and females of all age groups, but is commoner in the 10-30 years age group. The prognosis is especially worse below the age of 2 years and above the age of 90. At first, there is a sudden onset of abdominal pain. The pain is initially above the umbilicus in the center, and later moves to the right and below the umbilicus. The pain gradually worsens and can be associated with loss of appetite, nausea and vomiting. Fever too can set in. In this manner, abdominal pain, vomiting and fever in that order should make one suspect appendicitis. Examination of such patients always manifests certain signs. The pulse rate is increased due to the fever. When the right lower side of the abdomen is pressed, there is pain and the muscles appear rigid. Do not massage the abdomen when such pain occurs and do not take strong purgatives.
What tests are done to confirm the diagnosis ?
Many of the tests enumerated below are done on an emergency basis to rule out other causes of abdominal pain and to confirm the diagnosis of appendicitis. Blood tests : In case of appendicitis, there is a rise in the white blood corpuscle count. Urine examination : If there are red blood cells or pus cells in the urine, then there is a possibility of kidney stone or urinary infection. Stool examination : If there is infection in the intestines, then cysts of the organisms may be seen. Plain x-ray of the abdomen : The swollen appendix is not seen, but if it has ruptured then gas may be seen under the diaphragm and also renal stones may be detected if present. Sonography of the abdomen : Sometimes, a severely swollen appendix may be seen. Pus may be seen collected around a ruptured appendix. Other causes of abdominal pain in that area can be made out e.g.: right ureteric stone, in females swelling of the right tube or ovary. Laparoscopy : The need for this may be felt in young women. Nowadays, it is possible to remove the appendix by this method also. Screening has no value in the diagnosis of this condition.
What is the treatment for appendicitis ? In cases of mild attacks of non-obstructive appendicitis, sometimes medicines may be used as a temporary measure. For this anitbiotics and pain relieving injections along with I. V. drips are used. By this, an emergency surgery may be postponed and done later on at a convenient date. Repeated attacks of non-obstructive appendicitis call for planned surgery and for sudden obstructive appendicitis, emergency surgery is the best and standard treatment. Once the diagnosis of appendicitis is confirmed, then in the best interest of the patient, surgery must not be avoided or postponed, because more the delay, more is the likelihood of complications like adhesions of the bowels, mass formation, appendicular perforation, pus formation or spread of the pus all over the abdomen. There is a definite danger to the life of the patient if surgery is not done for perforated appendix. In case of females, the tube can get blocked and she may not be able to conceive at a later date.
How is the operation performed ? This can be as an emergency or can be planned. If there are no complications due to appendicitis, then the surgery is easy for the surgeon and less risky for the patient. A small 2"-3" oblique incision is taken to the right of the lower abdomen to remove the swollen appendix. This operation generally lasts 1/2-1 hour and only the part below the umbilicus is anesthetized. The patient can generally start taking liquids orally after 8 hours and can be discharged in 3-4 days and return for stitch removal on the 8th day. In case of complications, the operation is more difficult and risky for the patient. A 4"-6" long vertical incision is taken on the right side of the abdomen. The blackened or ruptured appendix is removed and the adhered bowels have to be separated and the pus from the cavity has to be cleaned. This increases the duration as well as the extent of the surgery, which may last from 1-2 hours and sometimes may need general anesthesia. The patient has to be kept on IV drugs for about 3 days and, many times, has to remain in the hospital for 8-10 days. In this way, the patients suffer both physically as well as financially.
Are there any risks in the operation ? Due to the rapid advances in the medical field, the surgery for appendicitis is not very risky any longer but if the surgery is done after some complications set in, there is a definite increase in the risk. The wound may get infected after the surgery, though this may heal with medicines and dressings. The appendix being a vestigial organ, its removal does not permanently affect digestion, nor does the appendix recur after removal. Surgery results in a permanent cure.