Right of confidentiality

One of my Patient visited me recently for a follow up visit.I think she sounded quite satisfied with the overall experience she had under my care but at the end of consultation gave me two feedbacks

• I should not have discussed her condition in front of her mother in Law
• I should not have gone to Germany for an official commitment just before her due date.

In Indian setting family members are usually a part of the final decision taken regarding medical condition of a person.5years back when I returned from UK I was much more sensitive of these issues as confidentiality,patient should be told the condition first even if it is cancer,to keep a chaperon while examining a patient to avoid any complaint of sexual assault etc.In last 5 years I do realize that these issues got a little diluted.I did loose the focus.I apologised her for her first complaint as she was perfectly alright in complaining about telling her medical condition in presence of people she would not have liked to know about it.This particular incident has made me once again sensitive to these issues as I was 5 years back.Thanks for the feedback!!

second feedback......I was not impressed.I am a human being first and doctor later.I have my personal as well as non clinical official responsibilities including conferences,courses etc which I need to attend to keep myself updated with the latest in my field of work.Now what I agree is that if some one is my Patient, should not be left high and dry if I am out of town.It is more correct for pregnant Ladies.That is why as a responsible person, I have a team where consultant level Gynaecologists
help me out in taking care of my patients in my absence.I have my team member Dr Deepa Maheshwari and the blog regular are already familiar with the name of Dr veenu.They are consultant level gynaecologist delegated by me ( not my hospital) to take care of any Lady who goes in labour in my absence.Even in western countries no doctor is working 24 x 7/365 days a week.Doctors are much more frequently on vacation than India.So in future if I am away rest assured that there are competent doctors to take care of you and advice you but I can't be expected not to move out of Gurgaon at all.These doctors have been trained by me and thus the unit protocol still remains the same even in my absence.

BTW from 3rd jan to 6th jan and then 29th jan to 3rd feb I am out of India.

Fundal pressure for second stage of labour

As luck would have been just yeaterday in Gurgaon Live,the supplement of Hindustan Times,I came across an article by a very learned doctor of Gurgaon on epidural analgesia.A very well written article but again 'the uterine pressure' for delivery was considered an option.I think we need to review our practice and follow the world wide accepted practice........where instrumental delivery is found to be a safer often than brute force of fundal pressure.
Few scientific evidences are as follows :

[Interventions during labor for reducing instrumental deliveries].

[Article in French]

Schmitz T, Meunier E.

Source

Maternité Port-Royal, hôpital Cochin, AP-HP, 123, boulevard de Port-Royal, 75014 Paris, France. thomas.schmitz@cch.aphp.fr

Abstract

Several interventions have been demonstrated, with high evidence levels (EL), to be associated with reduced instrumental deliveries and should therefore be undertaken during labor for increasing spontaneous vaginal deliveries. Using a partogram (EL1) and continuous support during labor and childbirth (EL1) lead to fewer operative vaginal deliveries. Systematic early amniotomy increases the frequency of fetal heart rate abnormalities (EL2) without decreasing the incidence of instrumental deliveries (EL1) and should thus be avoided. Early oxytocin in dysfunctional labor (EL2) and manual rotation of posterior and transverse presentations (EL3) may reduce operative vaginal deliveries. Even without epidural analgesia, any upright or lateral positions compared to supine or lithotomy positions do not reduce instrumental deliveries (EL2). Epidural analgesia alters significantly instrumental delivery rates and therefore patient management in the labor ward. Indeed, when used with high concentration of local anesthetic, epidural analgesia is associated with increased operative vaginal deliveries (EL1), at least in part because of increased posterior presentations (EL2). However, the effect of epidural analgesia on instrumental delivery rates closely depends from the type of anesthetic and concentrations used. This effect is reduced when low concentrations of local anesthetic are used in combination with fat-soluble morphinated agent (EL1). Finally, for nulliparous women with continuous epidural analgesia, unless irresistible urge to push or medical indication to shorten second stage of labor, delayed pushing is associated with reduced difficult instrumental deliveries (EL1). Fundal pressure maneuvers should be prohibited because of their inefficiency (EL2) and dangerousness (EL4).

Delayed diagnosis of an atypical rupture of an unscarred uterus due to assisted fundal pressure: a case report.

Kurdoglu M, Kolusari A, Yildizhan R, Adali E, Sahin HG.

Source

Department of Obstetrics and Gynecology, Yuzuncu Yil University School of Medicine Van Turkey. mkurdoglu@doctor.com

Abstract

INTRODUCTION:

Although rare, rupture of an unscarred uterus is one of the most dangerous obstetric complications, resulting in maternal and fetal jeopardy.

CASE PRESENTATION:

A 30-year-old grand multiparous Turkish woman without any history of uterine surgery gave birth vaginally at 37 weeks of gestation with fundal pressure applied in the second stage of labor. Transabdominal sonography performed 32 hours after delivery due to postural hypotension and a drop in hemoglobin values in the postpartum period revealed massive intra-abdominal free fluid. On emergency laparotomy, serosal rupture of the uterus on the left posterior side was observed. She underwent a subtotal hysterectomy and did well postoperatively.

CONCLUSION:

Postural hypotension in postpartum patients without any evident vaginal bleeding may be an early sign of possible uterine rupture, even if the vital signs are stable. Early diagnosis is important if maternal morbidity and mortality are to be decreased.

Uterine rupture: preventable obstetric tragedies?

Mishra SK, Morris N, Uprety DK.

Source

Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Dharan, Nepal. sangeetamishra2002@yahoo.co.in

Abstract

BACKGROUND:

Although ruptured uterus is nowadays a rare obstetric emergency in Western countries, it is still alarmingly common in developing countries, where it remains a major cause of maternal mortality and morbidity.

AIMS:

To review the recent experience of uterine rupture at a tertiary obstetric unit in eastern Nepal and to recommend improvements in the current management of labour, especially obstructed labour, in a poorly resourced country.

METHODS:

All cases of uterine rupture managed from March 2002 to March 2006 were identified retrospectively, and details were retrieved from medical records.

RESULTS:

Fifty-two women suffered from uterine rupture during the four-year period, approximately one woman per month. Most were unbooked multigravidae, with no antenatal care. They nearly all began labour at home in the absence of a skilled birth attendant. After prolonged labour, usually prolonged second stage, various interventions had often been attempted at home or in other health facilities before admission. Most were shocked and required urgent laparotomy and blood transfusion. Many required intensive care and ventilatory support. Forty-six per cent required hysterectomy and 5.8% subsequently suffered from a urogenital fistula. The maternal mortality rate in this series was 13.5%, and the stillbirth rate was 94.2%.

CONCLUSIONS:

Unsafe obstetric practices were identified, especially the injudicious use of oxytocic drugs and fundal pressure in prolonged second stage. Several achievable improvements in obstetric care are recommended, particularly aimed at reducing the delay in women reaching emergency obstetric care when labour is prolonged.

Fundal pressure during the second stage of labor.

Simpson KR, Knox GE.

Source

St. John's Mercy Medical Center, Women and Children's Care Center, St. Louis, Missouri, USA. KRSimpson@prodigy.net

Abstract

The role of fundal pressure during the second stage of labor is controversial and can result in clinical disagreements between nurses and physicians. Clearly the time for resolution of this issue is not when there is a physician request at the bedside in front of the patient. A prospectively agreed upon plan specifying how this request will be addressed is ideal. In order to develop this plan, risks, benefits, and alternative approaches to the use of fundal pressure should be reviewed by an interdisciplinary perinatal team. Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved. This article will review what is currently known about fundal pressure including risks, benefits, and alternative approaches. In that context, suggestions will be offered for a safe approach to managing the second stage of labor.

Comment in

• Fundal pressure. [MCN Am J Matern Child Nurs. 2001]

Epidural analgesia in labour-Facts and fictions

Epidural analgesia......whether it is good or bad?I think it is good as labour pains are really bad pain.But in this post I  don't wish to talk about my view point on epidural analgesia.It is all evidence based medicine.As chance would have been in last few days there have been many incidents involving me, ladies in Labour,expectant mothers ,other obstetricians and labour room nurses and anaesthetists.....and common factor was epidural and some associated myth about epidural analgesia.I realized that my years in UK have helped me understand epidural analgesia better.Would like to share the answers of some common queries:

Is epidural safe?What are the side effects?

It is !! But there  can be associated complications just like any other intervention and would depend on the competence of the anaesthetist. Accidental puncture of meningeal membrane can lead to dural tap with leakage of spinal fluid.It can lead to severe headaches .the definitive treatment is blood patch injected in the epidural space.It is recommended to deliver the baby by vaccum rather than allow the lady to strain to deliver the baby.

At times if the dose of local anaesthetic medicine becomes more it can impair diaphragmatic innervation and thus arrest of respiration.This is called total spinal.

Some ladies can be allergic to the local anaesthetic agent which is used.

Epidural at times can cause lowering of blood pressure typically after administration of bolus dose of medicine.It can lead to lowered pulse rate of the foetus and is corrected by putting the Lady in left lateral position and hydrating the lady.

It is a known fact that epidural increases the length of 1st and 2nd stage of labour and there is increased used of instrumental delivery.Anaesthetist at times are touchy about this fact and would not like use of a vaccum for delivering a lady who has been given epidural analgesia as this confirms the age old fact that epidural administration is associated with increased used of instrumental delivery.I have found my patients quite cool of the fact that a vaccum will be used if they are unable to push. I think most of them are well read people and they talk to me to clear their doubts. Few Gynaecologists like to push the fundus of the lady to deliver the baby if she is not able to push.This is perhaps not recommended in modern day obstetrics.Though technically a normal delivery and not a instrumental delivery it is much dangerous with a possibility of injury to spleen,liver,ribs etc. (Again if I had not been to UK even I  would be pushing the uterus hard.There they would have struck my name from the GMC register for something as dangerous as this)

When can epidural analgesia be given?

There is no arbitrary dilatation based on which the administration of epidural should be stopped.

Should the Epidural be stopped at the time of bearing down?

Many Gynaecologists stongly believe that epidural should be stopped when the ladies pain is at it's peak and when she is bearing down to help in getting her motor impulses back.Fact of the matter remains that once epidural has been administered it should be stopped only after 1st,2nd,3rd stage of labour as well as perineal repair if needed is all complete.There is no role of stopping the epidural intermittentely.

So , epidural will cause me life long back ache?

No...it won't.There is no evidence to the same effect.


Should I go for it or not?

If I had a competent Gynaecologist who can perform safe instrumental delivery and an anaesthetist who could give me epidural without a dural tap,I would have surely gone for it myself.


Dear patients of mine, anyone of you who would like to share their good,bad or ugly experiences about epidural are most welcome at my blog.

Free Health camp at Max Hospital ,Gurgaon

I shall be conducting free consultations on every aspect of gynaecological disorder from 3rd to 8th dec between 6 pm to 8 pm at Max hospital Gurgaon.There would be discounts on Pap smear and mammogram.If any one gets registered for any kind of gynaecological surgery (including all the major cases) would be entitled to a discount of 10% of the total bill if the surgery is performed within 30 days.There would be special emphasis on Urine incontinence surgeries and on advanced laparoscopic surgeries. 

My clinic pics

Property' Pachda'

Of late I haven't got any inspiration to write a new post.To write a post I need to be inspired either with a positive experience or a negative one.These days I have become numb as well as dumb.Reason being a poor doctor trying to buy a property to live in.In the process I realized Arranging finances isn't the biggest problem.There are many more battles to be conquered.So , with sky rocketing prices of property in Gurgaon I thought of purchasing a property sold by a friend in order to save some money.So that left me with no broker.Now imagine working at hospital,running an OPD,operating,delivering,doing caesareans,I have so much to handle.
A call from the bank......God a never ending list of paper work.Call from Gaurav ,the bank rep.Fixing time with managers was a big problem.I am free only in anti social hours.After 9.30 or 10.Imagine.....the trouble of meeting the managers so late in the night.It is still going on.Am yet not over with it.
Now I have to sell a property to purchase this property.So just imagine the number of people involved.My buyer has to arrange loans and thus to complete my deal I am dependent on him.If he is stuck which he is at the moment currently....then I will also find me breaking my commitment to my seller.
My seller and his wife live out of NCR.so even signing an ATS isn't so easy....needs coordination of presence of me,mom,seller and his wife.God save me.so again after I meet you guys in OPD I try to fulfill these commitments in night after 10 pm.
A visit to deed Writer.Purchasing stamp paper for registry  .........carrying cash in Gurgaon.......I DIDN'T FEEL COMFORTABLE.Waiting list at SBI.Gurgaon civil court.Nexus of Property dealers.Cheque and cash etc and etc.
You are also numb ,I now I know.So that is what is happening I see you guys at the hospital,operate and then keep on coordinating with bankers,writers,property dealers,buyers and sellers......and that just finishes the day.
just praying that it gets over soon so that I am back to be the clinician I was before I started with this Property Pachda.....Waiting for the time when I will get time again to teach my son.To relax on sundays.

My OPD slots and waiting

Tody once again a Patient wished me to increase my OPD slot duration to 25 minutes per patient instead of 15 minutes to decrease the waiting time.Less appointments and thus less waiting.

Dear friends that is not possible at any cost because I can't sit for 2 hours in OPD and see only 4 patients.It isn't financially viable option either for me or the hospital.

There are few ways in which you yourself can help each other and help me in decreasing the waiting time.Better time management by all of us.

You realize that that your consultation time is 15 minutes please come prepared with your queries.If you wish to save time ,Please don't expect me to answer all the myths that are generated in your mind  by your google search or your mom or mom in law or your friend if you wish the appointments not to run late.At the moment I do answer even your  smallest query which can take up to many minutes .

Don't ask me such irrelevant questions like 'how much is the rate of baby's heart beat when I have already told you that it is normal.

Please come on time.

When asking questions Please don't keep on beating around the bush.Respect my time and automatically the schedule will run on time and thus your time will be respected too.

Other option is to let it continue the way it is............you keep on asking the questions to your heart's content and me answering them......I don't have any problem when your 15 minute appointment runs to 45 minutes because I feel you need to understand the treatment and your condition to take care of yourself better.But if the waiting time bothers you,let us all try to do our bit to stick to the 15 minute schedule.Don't yell or shout at the duty Manager.He/she isn't at fault.Don't complain against the front desk staff for my waiting time.It won't help as they are not the ones responsible for it.It is You and me.You because you have taken more than your stipulated 15 minutes and me because I have obliged you.Do you realize that in this process my opd supposed to get over by 8 pm ends by 10 pm.Do you realize that at the end I have waited along with you????Next time think over it while waiting........And also at times there can be patients whose medical history is so complex that they need to give me a detailed history and I do need to give them time genuinely as well.

Some one also told me that with increasing competition ( I think she meant a Hospital coming across the road).......if the appointments are delayed it will be a bad name for the Max Hospital. :-)) I find this comment really funny.And fortunately her husband also found it funny too.Pleaded her to keep quiet,reminding her that in this whole process she had already spent 25 minutes with me instead of her allocated 15 minutes.Reminded that she had to wait for hours for the doctor in South Africa too .  

Shortage of Rooms and waiting list

This season has been quite bad with lot many cases of Dengue,Malaria and all sorts of viral fever.All the hospital beds have been occupied and there has been shortage of beds in almost all the Gurgaon hospitals.There are many angles to this shortage or crisis of bed. Angle of patients……,Angle of doctors……and angle of hospital administration.

I as a gynaecologist with many patients in labour and with gynaecology operative cases would grumbe when informed by the front desk of their inability to provide the desired category of room to my patients. I would fight with them. The Ladies in labour come to the hospital for the ‘experience’ and they are also not happy with a crowded hospital and they want the single room they are entitled to as per their insurance. They feel cheated if they have been given a room which is double sharing or triple sharing room till the single room is vacated for them to be allocated their desired room and rightly so(After all they are paying for it). The payment is as per the room cap they are entitled too .Their complaint is but natural.
 I recently read a review on a blog to the same effect. The review said that the bills of a pregnant Lady were made to show some targets. They found the reception staff to be rude, which I doubt as I have seen them taking a lot of  misbehaviour, anger and very unkind words from anxious relatives day in and day out. We also should realize that the front desk staff is also over worked when there are so many discharges and admissions are happening round the clock. Hospital is making money but then they never said they were in the business for charity.Front desk staff don’t have any such targets as to inflate the bill. They are paid salaries and just do their job.They are not supposed to generate any revenue.Except for the Managers and HODs no one has to show any numbers or reach any targets,Rest of us work peacefully.

Another angle to this shortage of bed problem. A person who has come to the hospital as they are really unwell .A perspective is now of a mother whose child has dengue and is running 105 degree F temperature since last 3 days and hardly been  able to stand  or eat.He is acutely dehydrated and needs a hospital bed. This mother is me and the patient is my son……….and my fronk desk is helpless as they don’t have beds .I am upset and my front desk is upset too……..they like me and wish to find a bed for my son as soon as possible but how can they create a room?To me at that point of time his need to get admitted looked more important than the need of a pregnant mother who is there for an experience.She needs a bed but my son need a bed before him.That is how exactly the relatives of other sick patients must be feeling. As a mother ,I felt I damn care if the lady in labour is admitted or not but my sick son should be admitted .I just needed a bed. Luxury was the last thing in my mind.

Now coming to the hospital……..they do make money once patients are admitted .But they make much less money from a dengue patient occupying bed for a week than from a vaginal delivery patient in just 2 days.If the hospital was just for making money they would have just given preference to pregnant ladies and let sick serious Dengue patient go back and find ways to manage themselves.

Before writing a review it is important to understand the complete picture,my humble request to all the bloggers etc.Please just don’t write,Max Cheats…please elaborate and give evidences.Don't just presume.

Now another incident.I was constantly working since 8 am in the morning on last Saturday without even a pee break and with 101 degree fever.( Why was I working? For money……..as some of you would say. Yes for money but that was not the only reason. Suppose I get my OPD cancelled the same day, it will cause discomfort to you only when you get an unceremonious call from the hospital telling that I have blocked my OPD .And even if I am unwell and my patient is in labour,do I have the Liberty to say I am sick won’t take care of you at the end of nine months??)Someone was shouting outside my OPD around 4 pm.Came to know that an appointment patient had been waiting for 30 to 35 minuts and was getting restless.Husband  had called the duty manager and was blasting him with suggestions like lengthen the slots allocated to the patients if patients take more time than allocated .lessen the number of appointments then!! Simple….that person has shown his wisdom. Now there are few practical problems. Suppose you have 15 minutes appointment with the doctor.But you wish to talk to the doctor and understand the doctors advice and till you aren’t satisfied even if it takes 45 minutes you won’t mind even if you realize that you have taken much more than your share........………..if a doctor interrupts the doctor is labelled a money minded doctor who doesn't give enough time to the patient. .Should I be asking that female to leave me as 15 minutes are over?I will find it very rude!!Now if one patient has taken 45 minutes extra the OPD as a whole gets delayed by 45 minutes .Now who is at fault?You,me or front desk.In my opinion no one actually.

As far as decreasing the number of slots for appointment………….a BRIGHT idea as an individual patient. But there are quite some downside

That would mean I should see 2 patients in 1 hour. And in this manner the patients who have to come for follow ups will have a long waiting list of 6 to 7 months as in NHS.Are you willing for that?And I can’t survive if I work at a pace like to see 4 patients in a day.

I did try to make the couple understand why these delays.I hope they understood and took it positively,At 101 temp even I don’t feel like talking non stop to patients from 8am to 9pm with two high risk caesareans in between without any time for food or drink.
PLEASE USE  public forum sensibly know every aspect of the the topic covered by you and then only can it be a useful Max Hospital Feedback other wise it just comes across as a medium to vent out your frustration.

Construction of new Vagina following a 'mutilating' surgery

I wish to share with my blog readers are very unusual case,not very commonly seen.
A Lady in her late twenties visited me from Panipat.Her relative who is an old patient of mine had brought her to me.
The history was that this Lady had a Normal Vaginal delivery about 2 years back.After that some obstruction was foundat the vaginal opening which the gynaecologist conducting normal delivery had agreed to correct.Having lost their faith,the couple went to another doctor and then never took any treatment for two years till when they started planning for second child.The Lady found the sex excruciatingly painful and penetration wasn't adequate and thus they came to Max hospital ,Gurgaon to meet me.
When I examined I found a very shallow vagina with some curtain or wall kind of structure within an inch of the mouth of the vagina.
I planned to operate her next day and what I found was amazing.There was a thick secondary septum due to fibrosed tissue with a pin head size opening.Perineum was tight.I slowly dilated,corrected and refashioned her vagina along with correcting the perineal tightness by Fentons procedure.After clearing the septum,I found that the cervix was also stuch to the vaginal wall.

I don't know the reason why something like this should happen in a lady who had a vaginal delivery not long back unless she had some severe infection or the vagina was closed too tight.So whatever might be the reason.I felt happy after correcting her problem as it must have been a living hell for her.

Here we start at clinic Nirvana

I am pleased to inform that my clinic at clinic Nirvana at C 209,Nirvana Courtyard,Nirvana Country,South city II will start from 22nd october 2012.  We have already started taking the appointments.How thing will work is as follows:

For my clinic appointment please call my practice Manager Ms Sarah at 9899559807.

For my appointment at Max ,please call Max reception.

My timings at clinic Nirvana would be

Monday 5 to 8 pm
Tuesday  10am to 1 pm
Wednesday 5 to 8 pm
Thursday 10am to 1 pm
Friday 6 to 8 pm
Saturday 10 am to 1 pm.

Hope this would be a convenience for people living in Nirvana Country,South City 2,Sohna Road,Sector 56 ,Sector 57 etc.

Dengue

Dengue is rampant in India in this season.In my household,first it was my house keepers 21 years old son and then the 16 years old boy who works at my home and now my 12 years old son.

Currently my son is under hospital care and doing well.Why I  felt the need to write this post was to share a little bit more information about the condition.The word dengue spreads a feeling of fear and a dropping platelet and platelet transfusion to a common persons mind.And rightly so.

A golden rule.......see a physician or a doctor who understands the whole dengue disease and the associated management.One or rather two very competent surgeons questioned the need for hospitalization in dengue as it has no cure.Sorry to say but then these guys might be very good in their respective speciality but not masters of all medical field.Why I am mentioning this line at the risk of irking them is that as a common man,for you all doctors are doctors and you tend to ask a 'big doctor' of unrelated speciality who also happens to be a family friend......what to do?If not knowing the disease process well you might be made to think.....no big deal with disastrous results.People do loose life with it.

It is a viral fever which doesn't have any cure as I have already mentioned and body slowly comes out of the infection.While the infection is ongoing it can be very mild with just fever with little changes in the blood tests and patient though with fever is over all not lethargic,not having any bleeding tendency etc.But at the same time it can be quite bad.Initial 3 or 4 days the patient has very high grade fever.There is a phenomenon called   haemo concenteration taking place,which I would say in lay man term is that body is severely dehydrated and fluid requirement goes tremendously high.If not compensated for could be one of the reason of collapse and shock seen in patients with not very low levels of platelets. Not all patients showing downward trends  of platelets will need platelet transfusion.
To summarize ...don't panic but take it seriously.Consult only a specialist and not a doctor family member of doctor family friend who doesn't understands the interpretation of such subtle blood test.

Take care.

The mystry of Ovarian Cyst

I love movies with happy endings.You might say,what is so special about it we all do!!As a child I used to enjoy all the horror movies and tear jerkers...........but not anymore.Don't watch such movies any longer.
But can't control the real life.It is a mixed bag.
So yesterday there was a young unmarried lady who I operated for a suspected Ovarian cancer but on putting the laparoscope turned out to be a dermoid. Histopathology is still awaited but the clinical sense says that she will have an happy ending.But not everyone is so lucky.
There are patients whom you never forget in your life for some reason or other.There was one such girl called Pooja.Many years back when I was a registrar ,almost 12 years to be precise.A girl around 20 yrs came to the OPD of my aunt Dr Shakti Bhan Khanna. An angelic looking girl.Her beautiful eyes were filled with tear as she gave her history.She told ,I have a swelling in my abdomen and my parents think I am pregnant while I have never been sexually active.We assured her that it was very easy to prove that she isn't pregnant.An ultrasound later it was found that she had dermoid cysts in her both ovaries.The girl was not sure whether to be be happy with a proven point that she isn't pregnant or to cry with ovarian cysts as the reason of her swelling.Her next visit was with her parents who were very tense.They were reassured that though she would need a surgery but dermoids are not so sinister after all.
And then she was operated.Beautiful Bilateral  cyst removal done.For some reason despite a beautiful surgery she had mild post operative ileus ( her guts were slow to recover and tolerate food).
Fine and finally came her histopathology report.It suggested 'immature teratoma',a variant of dermoid with borderline malignant potential.A frozen section was done at the time of surgery as tumour marker were normal and CT scan suggested a dermoid. It was sad.Then she underwent chemotherapy,lost her hair (though temporarily) .It was the beginning of my career and not used to such tragedies,I was also found it difficult to deal with.I am not sure what happened later as ever since I moved to so many places and didn't ask my aunt about Pooja's follow ups.Later on I came across and still continue to come across many other such stories with not so happy endings.......but Pooja is the one whom I will never forget and any young girl with ovarian cyst reminds me of her....always.

Should a pregnant Ladies husband be allowed inside the OT?

When I had my caesrean my masi Dr Shakti Bhan Khanna was the suregon ( Couldn't have asked for a more competent person,who can perform an internal iliacc artery ligation in seconds if needed),the anaesthetists were doctors whom I had been calling mama and masis since I was a child.And I was a qualified Gynaecologist.I felt like the whole family was there with me.It made me very much relaxed.I chatted with the anaesthetist as my boy was delivered.So over all a very nice experience.

Now imagine a Lady in labour,in one of the most vulnerable states of her life shifted to OT and surrounded by all men/women in green and blue.It must be little scary.Every one in rush to get the things done in order and meticulously.I have seen by my own eyes that once the husband is allowed in the become calmer and cooperate better.Even many scientific papers in pubmed recommend presence of the birthing partner during delivery.
In Uk it was kind of rule.Lady and her birthing partner would be present in LR as well as OR.After 4 years of mu Uk training when I returned back to me it was pretty cool if a husband wished to be inside the OT or LR.Then once my dear friend Dr Rohit Jaswal who was the anaesthesia HOD then,objected to it.He said that neither any other gynaecologist wishes to encourage this practice nor was he in favour of the partner being inside the OT.We discussed and on the basis of evidence I could prove my point and got the permission for my patient's partners.
Slowly others also had to agree as in the same hospital patient start asking about the dichotomy of behaviour and rules.
After so many months ,why am I talking about it?
There is this very nice OBGY Forum on FB where doctors were discussing the same issue.
Even now all the partners are most welcome inside but as long as they understand that they are allowed in to give the emotional support to the wife.Clicking a picture or two is Ok but if the doctor requests you not to do that please listen to him or her.Reason being your effort to get best angle might just distract the doctor from the operating field,which can be dangerous.
Even when it comes to caesareans many doctors feel conscious about letting the partner in.The doctor has a right to say no to you.You as a patient has a right to ask for letting you partner in.If it works fine that is great but if not it is your right to change your doctor just like it is the right of the doctor to say no to you if they don't like any intrusion in the OT.
If caesarean is done under GA then there is no sense anyways for the partner to be in as the wife would be knocked off and will not need any emotional support.

Many a times during non child birth surgeries partners whish to be present inside the OT.That serves no purpose because a lady under General anaesthesia won't need your support. 

I thought I was very intelligent......but not any further

My head is spinning badly.It is 54 minutes past midnight and I am here solving a real life drama and mystreyIt looks some suspense movie starring Kareena and saif..As if I already hadn't enough on my platter.
On 15th of september after interview of two young ladies around 25yrs of age ,I employed a well qualified girl to be my practice manager ( Secretary).She was from Banglore and a MSc in Biotechnology and wishing to make it big in the corporate world.Both these girls were fine but the one I selected looked every inch a Hizab covered Muslim Girl from Banglore as she should have looked,Very decent and degnified.My clinic wasn't yet ready so I started bringing her to Max.The idea was to make her understand the working of corporate hospital as well as patient handling while sitting at the reception.With me at times it can be quite late before one is free from the OPD. So her cousin used to come and pick and take her home or PG where she used to stay.
Can't deny she was picking the things well.Had made friends at the help desk and nurses.She looked a 'shareef,siidhi saadhi,as I said Hizab covered girl.I was also protective about her as I felt her to be too innocent for our Gurgaon.
Now today she sent me a text.....Mam will be delayed.Will come by 11.30 am.I didn't like it as it hasn't been long since she has started working but then Ok.......Then after finishing the first half of my work at Max when I reached home she wasn't still there.Then around 12.30 she came to me and was crying.Crying at the tyranny of her parents.How she didn't wish to go to Bangalore and how her father was compelling her to come back home today itself .She was crying and constantly saying sorry to me.And then she got a call and I could see her anguish.She was requesting papa don't taking me back,I wish to work.I know you will not send me back.I offered to talk to the papa.A old man's voice came from the other end.Let her come for 3 days and then I will return her.Her mom is unwell.Emergencies don't come after informing and so on and so forth.And again this girl was like...no papa no.
Well I asked her to sit at the office till papa actually came.An hour later I realized that she was missing.I said few bad words for her parents for making such a nice girl so upset.
During my evening OPD her cousin came to the hospital searching for her as she wasn't picking the phone.I blamed him as well for not being kind to the girl.
As the story unfolded........I was shocked to know that I was made to speak to some man who wasn't the PAPA.Original Papa called just now to tell that she was sent to Gurgaon so that she can be away from a boy from Bangalore and had never asked her to come back.He was talking to me for the first time.
It hit me like a thunderbolt........so she created a fake papa to make me believe her.God.Damn it.Who can one trust.At the moment his Cousin is searching the reservation list of Karnataka express at Delhi railway station to find if she is one of the passenger eloping with some one.Another theory is that her Bangalore friend has taken her to Bangalore already by flight...........A shattered father and mother,crazy going Cousin and bewildered employer i.e me......Kaushiki don't judge the book be it's cover........actually you don't.What happened this time? 

My new website

Dear Blog Readers,

I have updated my website www.drkaushikidwivedee.com  and would request you to visit the site to know the changes that would be there in my practice timings and places.

• My personal clinic at Nirvana Courtyard (CLINIC NIRVANA) would become functional latest by 3rd week of this month.I hope that will help in streamlining my appointments as most of you have complained of unavalibility of slots at Max Gurgaon.
• I intend to spend my OPD timings equally between the two places i.e Max Hospital Gurgaon and Clinic Nirvana.
• For appointments please call 9899559807.
• For clinical queries you can use my personal mobile number and would prefer a text to a call.I find it more convenient.

                                                                                     

                                                                                               Love

                                                                                              Kaushiki

                                                    

What are Leaders made of ?

On 6th of October there was an offsite organized by Max healthcare which was called clinical leader offsite.It was my good luck to be a part of it . Not because I was 'chosen' as one of the 'clinical leader'but because I could meet and see and observe some such great leaders closely.
       
          This is a general human tendency to dismiss a successful Industrialist or a politician or writer,as being 'you know it was because he/she was born with a golden spoon.His kismat was very good.He is cunning .He is corrupt...so on and so forth.

           It is not just Kismat or corruption.One has to be different from the crowd...... from the rest of us to be great.They are different.Working in the organisation since last 5 years I met Mr Analjeet Singh for the first time and heard him speak for the first time.It was an extempore speech which were basically answers to the questions put by the audience.I heard him and boy I was impressed.During 99 % of the speeches I fall asleep but I was mesmerized. He doesn't need my acknowledgement to be considered for what he is or who he is,but I think I gained a lot listening to him.Successful people are clear in their vision and thought and they are able to express it plain and simple to the audience.They dare to think different and they work hard,up to 16 to 18 hours a day and they have the capacity to convince you of their thoughts..

         Then it was the turn of Max MD Mr Rahul Khosla .He spoke two or three lines.And again ,you knew what he wanted to convey and he conveyed clearly in not many words.Here was a leader .....you knew.

        I am impressed......I wish to learn from people who are Leaders with their pluses and their minuses.Just searching for a person around my working place who is a leader and from whom I can imbibe some tips.........

But then I think such leaders are born and not made :-)

Intra uterine foetal Death ( IUFD)

Intra uterine foetal death is a morbid topic to talk.But it is a fact of life and pregnancy.No gynaecologist can escape it and neither could have I.
Yesterday I was revising my RCOG Guidelines on IUFD.It is always good to study.Keeps you up to date and makes you a confident doctor.You know what your talking or dealing with.
And slowly as I was reading my mind wandered to all those IUFDs which (Late Pregnancy losses inside the womb) my patients had in my last 5 years of private Practice as senior Consultant at Max Gurgaon.I could recollect 3 of them very vividly.
First one was in the very first year of my practice.I am not sure wether it was IUFD or fresh still birth which happened after the admission .That is an enigma to me still.There was this lady who had PCOD,had conceived under my treatment for PCOD.Her scans till level 2 scan were reportedly fine.She was obese and was gaining constant weight as pregnancy advanced.It looked like an avg size baby.She was gaining 1,5 to 2 kgs every month.And then she came in labour at terh.I as well as my registrar put a CTG machine and thought there was the foetal heart beat which vanished suddenly.Asked for scan.Showed a loss of heart beat.Baby was growth retarded.I had failed to pick the growth retardation it seemed due to belly fat.The liquor around the baby was hardly any.Baby had potters syndrome.The ultrasonologist had missed it.So I delivered a dead baby.I don't know whether the baby was live on arrival and died after the CTG machine was put in or actually we mistook the MOTHER'S PULSE FOR BABY'S HEART BEAT,
 The baby's father then mentioned that ultrasonologist suspected some problem with bladder filling but she never mentioned it on paper.The HOD radiology came to the defence of his team witha book which suggested that for bladder problem a repeat scan at 24 to 26 weeks was needed.So if I didn't ask for it ,it wan't  his team who was at fault.My HOD tried to 'save' me by saying the baby had died before the mother came to the hospital.I like a stupid fool kept on insisting....I did hear the heart beat on admission.Any ways the parents wished to sue the radiology team.I insisted'the fault was mine if I took body fat for baby's growth'.Sue me if you have to.And despite their grief they said a big NO.Doctor.......you can't be wrong.I felt their pain.And then for a short while till they left the town they always came back to me for any gynaecological advice.I was the blessed one.My patient's trusted me.Atleast they trusted my intentions.
Second one was even more sudden.A on going healthy pregnancy.C/o sudden loss of foetal movement at 32 weeks.She kept on waiting for 24 hours of loss of foetal movements.Primigravida.Usg later.....No heart beat.Was actually difficult to break the news.I cried and they cried.It was bad.Anyways....terminated the pregnancy.6 weeks later showed antiphospholiid antibody positive.I had a reason and a treatment to offer.They never returned back to me for their second pregnancy.But it was painful.
Third one had a happy ending.There was this too well read a lady with PCOD with GDM who had big fights with her husband and her in laws.In my opinion all of them were contributing to the fight.At 34 weeks,reported to Max emergency with no foetal moveents.USG.IUFD.Counselling wasn't too difficult.She was prepaired for the worse due to loss of foetal movements and being a well read person as she was.Her in laws thought me to be an unlcky doctor for her,suggested change of doctor and suggested me to do a hysteroromy.Challenged their daughter in law if her doctor would be able to deliver the baby vaginally.Anyways she did deliver vaginally.Even I thought she was someway responsible for foetal death due self induced hypoglycemias with insulin leading  to foetal hypoglycemia.But baby was born it had 5 to 6 tight loops of cord around the neck.I felt ashamed to have been judgemental.Anyways despite her family's objection she returned back to the doctor i.e me whom her family had declared unlucky.She had her whole pregnancy on insulin.At 38 weeks I induced her and she had a bonny baby girl.
It was a roller coaster ride for me all the three times.
Usually following an IUFD the doctor is considered unlucky whether actually contributing to it or not.It was good that my patiets showed faith and returned back to give themselves and me a second chance.

Believe me IUFDS are no less traumatic for a doctor.....

Back from Germany

First of all ,sorry to all my patients who had any trouble due to my being out of Gurgaon for 5 days.Though I try to insure that none of my patient is left unattended in my absence.I have a team headed by Dr Veenu Agarwal which insures that you are managed in my absence as per the same protocol as created by me after research of evidence based Management.So whether I am in town or not under the care of my team your management will still be the same.

Now that isn't what the post was about.It was about my Germany Visit.This Visit was for a specific reason.Those who have been following my blog must be aware about my passion to follow urogynaecology and to treat patients of Urinary incontinence who keep on suffering in silence for long years.Are scared even to sit on a sofa at their home lest they might wet them.

At Max Hospital with the support of our CEO and GM Operations I intend to start a full fledged Urogynaecology department.My visit was related to it only.It was a masters workshop at Ehingen City,Germany.The idea was to see what other masters are doing and whether you should do things differently.

It was a highly successful trip and I came satisfied that we won't be providing a care an less than the best of urogynaecology centres in the world to such patients.Follow my blog to get an update soon.In the meantime if you or any one of your family member has an incontinence issue......don't shy.Help is very near. 

How reliable are online feed backs?

Have you ever been a part of any matrimonial or dating site?May be yes.Have you ever come across a fake profile?Looks to kill,job profile which few can match ,family background .....you don't have words to compare.And finally you realize it is a 100% fake profile created for a time pass or if not fake a lot of information is morphed.

Now coming to online reviews of doctors.......are they to be 100% believed or should you disbelieve it or take it with a pinch of salt?There is this one site where the blog master has very painstakingly tried to give an overview and published reviews of various people about different aspects of Gurgaon.And in my opinion he is doing a good job.There is one section there on Gurgaon Gynaecologists as well.Recently there was one Lady who shared her concern if what is shared in the blog are actual reviews or just promoted a few gynaecologists.There are a few positive reviews about me too on that site and thus I feel my moral obligation to answer this question.And people do come to me reading those reviews.

I personally don't know the blog owner .His favoured gynaecologist is someone else and not me and even at the cost of irking him I would say that he surely has a biased attitude for her but the reason is simple.....he is satisfied by his wife's Gynaecologist.Just like anyone of you he is entitled to his opinions and feed backs and it might be so that he might slightly favour her by deleting not so favourable feed backs about her.Coming to me....as my online presence is quite significant due to multiple reasons.....one I like to be online and communicate with my patients.Secondly in Gurgaon it is a very good marketing option due to huge number of net savvy people.Thus my patients are also quite net savvy and I do have an advantage that they are their to give their feed backs.Of course it has it's disadvantages too....if someone is dissatisfied there is a good chance that I would get bad reviews online as again, a vocal online person will give a negative feedback too.

Now the question is whether to trust these feed backs or not?Please take it with a pinch of salt.These online reviews are just one way of finding required information.Try to find people in real world and not virtual world only who can give you feed backs.Try to ask the concerned hospitals.Try to find the educational qualification and experience of your doctor.There might be actually many good doctors who don't have a good online presence.

If I wish to give false and fake reviews I can do so.No blog master can stop me despite his /her best efforts to keep me from giving fake reviews even if he/she wants to publish only genuine reviews.I can ask 10 different friends and relatives to use 10 different ids/IP addresses/computers and write  reviews sitting at 10 different parts of the world.Where ever I travel I can myself use different Ids at different cities to write it all myself.Who needs even friends or relatives for that.It is still much cost effective than spending Lakhs on marketing.Do you think that blog master would be able to say for sure whether it is a genuine review or one prompted by me???Same goes for anyone..........

HAPPY SURFING :-) :-)   

Pregnancy in a Post Bariatric surgery Patient

Obesity is on rise and so are post bariatric surgery patients.I am not sure whether about the whole concept of loosing weight by such drastic surgical means.Being married to a expert bariatric surgeon Dr Shalabh Mohan......I do have a fair amount of knowledge about the physiology,emotional and physical issues faced by these patients both pre op and post op.According to him and the evidences which he has showed me it is a extreme step towards loosing weight but then probably these are the people who if hadn't gone for these surgery would have never lost the weight themselves once morbidly obese, had a miserable social life and would have had their life shortened by diseases like Diabetes,raised blood pressure,heart disease etc..

Now I have started getting women who are pregnant and had Baratric surgery.Two of them have already delivered under my care and few others are currently pregnant.They are quite apprehensive ladies.The clinicians who were taking care of them before me also seemed little panicky in their management of these women.Do we really need to panic?What are the special precautions needed by these women during Pregnancy?Let me summarize it .

Which Procedure ? A Lady desirous of having a pregnancy and opt for Gastric sleeve or bypass.Once it was considered that bypass was a big no no for lady who have yet to conceive as the deficiency of nutrition was considered to be more in bypass.It is a fact but the deficiency is marginally more and not of significance.In bargain the weight loss is more with bypass ( again whether all this is healthy or not I am not commenting on that.It is for you to decide and the Bariatric surgeon to counsel you)

When to conceive? Ideally once the weight loss has has stablized.Mostly the recommended timeframe is 18 to 24 months.Till then Oral contraceptive pills shouldn't be used for contraception as the faliure rate is high due to lesser absorption of the medicine.

Preconceptional Planning? Meet a gynaecologist as well as Bariatric surgeon.These women should be tested of their micronutient levels preconceptionally and then in each trimester.These micronutrients are Iron,ferritin,folate,Vit D,Vit B 12 and serum Protein.
These women should be supplemented with multivitamins,iron,calcium and if deficient in protein on high protein diet.

Diet during Pregnancy? Diet should be same as pre pregnacy diet.If someone has a difficulty in swallowing high fibre diet like green vegetables it can be made semisolid by pureeing in a mixer.

Very sweet food should be avoided just like in prepregnancy food as it can lead to dumping.....sensation of abdominal pain,nausea and vomiting.As one can get abdominal pain,nausea and vomiting as symptom of pregnancy as well a bariatric surgeon should be consulted to rule out dumping as the reason of these symptoms.To compensate for the 300 kcal required extra during pregnancy these women should have frequent small meals.There is a small probabilty that these women can have small for date babies and serial growth ultrasound scan is recommended on a monthly basis.Micronutrients should be supplemented during the pregnancy.In nutshell it isn't much different from a routine pregnancy.

Delivery? Caesarean section is recommended for only obstetric reasons.

Bariatric patients have a lot of preop as well as post major emotional issues and are advised to be in touch with a good bariatric surgeon who can be their counsler and can provide them the much needed support.It will also be a good idea to join a post bariatric surgery support group sessions.
 

Doctors don't always write investigations to make money

On Monday I shall be doing a completion  cancer surgery on a woman on whomn I did a surgery 10 days back.I have mentioned about this Lady in my earlier post as well.
52 years old lady,detected with both sided Ovarian cyst with normal tumor markers.....declined Frozen section.Frozen section tells about any organ being cancerous or not so that one can proceed for the extensive cancer surgery.
But that this lady didn't distrust me but thought why to spend on frozen section and if in case it is a cancer the money on cancer surgery.I opted to reduce my surgical fees........which was actually peanuts in comparison to he whole estimated bill at hospital.So she ended with a TAH +BSO ( removal of uterus and ovary)Despite bad adhesions I managed to take the cysts out with capsules intact......just in case.And it turned out to be a cancer.
Then I sent her to Medanta to a very well known medical oncologist for a second opinion regarding a need for completion surgery or a direct chemotherapy.
The Medanta oncologist asked her to get operated at his place.
Anyways she has returned back to me and on monday we are planning an extensive staging Laparotomy.
If only she had trusted that doctor would suggest a test only if needed she would have been saved of great amount of money and post op discomfort.
This is just and example..........there are many such.Will keep on updating on the blog .............not to justify the doctors or myself but to let you understand that health is a serious issue take it seriously!!
And yes........please all of you get your health insurances done.Treatment at quality hospital by quality doctors in India is quite costly.

Weight Watch

Our Lifestyle has changed.As I child I think months used to pass by without going to any outside food joint.My dad was a foody but a foody of different sorts.He used to invent variety of healthy dishes like all sorts of chillas,mixed rotis and quite a lot of such food stuff which finds it's place in a dietician's chart.He never used to cook but had trained my mom to do that who hated cooking as much as I do.Anyways what I mean to say that eating out wasn't a frequent option and there were lots of variety at home but all of them were healthy food stuff.
Today what I find is that my son wishes to eat out every weekend i.e is a  different question whether I oblige him or not.There are kids in family who loose appetite at the mention of home food but can finish tubs of chickens at KFC or full paneer plate at Bauji ka dhaba.
So what are we heading for? A generation with high probability of obesity,early age of periods,Precocious puberty,cancer.....they loath vegetables and fruits the main antioxidants.When alcoholism has become a part of our generation our kids would surely follow the path shown by us.There are kids who have tasted Breezer and are so cool about it and parents just laugh it off.A child in family wishes to have water only from beer can.Amazing!!Jai ho........
Now as we do expect obesity affecting people in big way let me share a very informative patient information leaflet of RCOG ( London).Hope it is of some use to all of us.Happy reading ;-)

Here follows the guideline on obesity...........


Most women who are overweight have a straightforward pregnancy and birth and
deliver healthy babies. However being overweight does increase the risk of
complications to both you and your baby. This information is about the extra care
you will be offered during your pregnancy and how you can minimise the risks to
you and your baby in this pregnancy and in a future pregnancy. Your healthcare
professionals will not judge you for being overweight and will give you all the
support that you need.
What is BMI?
BMI is your body mass index which is a measure of your weight in relation to your
height. A healthy BMI is above 18.5 and less than 25. A person is considered to
be overweight if their BMI is between 25 and 29.9 or obese if they have a BMI of
30 or above. Almost one in five (20%) pregnant women have a BMI of 30 or above
at the beginning of their pregnancy.
When should my BMI be calculated?
You should have your BMI calculated at your first antenatal booking appointment. If
you have a BMI of 30 or above, your midwife should give you information about the
additional risks as well as how these can be minimised and about any additional
care you may need. If you have any questions or concerns about your BMI or your
care, now is a good time to discuss these.
You may be weighed again later in your pregnancy.
What are the risks of a raised BMI during pregnancy?
Being overweight (with a BMI above 25) increases the risk of complications for
pregnant women and their babies. With increasing BMI, the additional risks
become gradually more likely, the risks being much higher for women with a BMI
of 40 or above. The higher your BMI, the higher the risks.
1
Why your weight matters
during pregnancy and
after birth
Information for you
Published in November 2011
If your BMI is less than 35 and you have no other problems you may still be able to
remain under midwifery led care. However if your BMI is more than 35, the risks to
you and your baby are higher and you will need to be under the care of a
consultant.
Risks for you associated with a raised BMI include:
Thrombosis
Thrombosis is a blood clot in your legs (venous thrombosis) or in your lungs
(pulmonary embolism). Pregnant women have a higher risk of developing blood
clots compared with women who are not pregnant. If your BMI is 30 or above, the
risk of developing blood clots in your legs is additionally increased. For further
information see RCOG Patient Information: Treatment of venous thrombosis during
pregnancy and after birth.
Gestational diabetes
Diabetes which is first diagnosed in pregnancy is known as gestational diabetes. If
your BMI is 30 or above, you are three times more likely to develop gestational
diabetes than women whose BMI is below 30.
High blood pressure and pre-eclampsia
A BMI of 30 or above increases your risk of developing high blood pressure. Preeclampsia
is a condition in pregnancy which is associated with high blood pressure
(hypertension) and protein in your urine (proteinuria). If you have a BMI of 35 or
above at the beginning of your pregnancy, your risk of pre-eclampsia is doubled
compared with women who have a BMI under 25. For further information see
RCOG patient information: Pre-eclampsia: what you need to know.
Risks for your baby associated with a raised BMI include:
● If you have a BMI of 30 or above before pregnancy or in early pregnancy,
this can affect the way the baby develops in the uterus (womb). Neural
tube defects (problems with the development of the baby’s brain and spine)
are uncommon. Overall around 1 in 1000 babies are born with neural tube
defects in the UK but if your BMI is over 40, your risk is three times that of
a woman with a BMI below 30.
● Miscarriage - the overall risk of a miscarriage under 12 weeks is 1 in 5
(20%), but if you have a BMI over 30, your risk increases to 1 in 4 (25%).
● You are more likely to have a baby weighing more than 4 kg (8 lb and 14
ounces). If your BMI is over 30, your risk is doubled from 7 in 100 (7%) to
14 in 100 (14%) compared to women with a BMI of between 20 and 30.
● Stillbirth - the overall risk of stillbirth in the UK is 1 in 200 (0.5%), but if you
have a BMI over 30, your risk is doubled to 1 in 100 (1%).
● If you are overweight, your baby will have an increased risk of obesity and
diabetes in later life.
2
What are the risks of a raised BMI during labour and birth?
There is an increased risk of complications during labour and birth, particularly if
you have a BMI of more than 40. These include:
● your baby being born early (before 37 weeks)
● a long labour
● the baby’s shoulder becoming ‘stuck’ during birth. For further information
see RCOG Patient Information: A difficult birth: what is shoulder dystocia?
● an emergency caesarean birth
● a more difficult operation if you need a caesarean section and a higher risk
of complications afterward, for example your wound becoming infected
● anaesthetic complications, especially with general anaesthesia
● heavy bleeding after birth (postpartum haemorrhage) or at the time of
caesarean section.
How can the risks during pregnancy be reduced?
By working together with your healthcare professionals, the risks to you and your
baby can be reduced by:
Healthy eating
The amount of weight women may gain during pregnancy can vary greatly. A
healthy diet will benefit both you and your baby during pregnancy. It will also help
you to maintain a healthy weight after you have had your baby. You may be referred
to a dietician for specialist advice about healthy eating. You should aim to:
● Base your meals on starchy foods such as potatoes, bread, rice and pasta,
choosing wholegrain where possible.
● Watch the portion size of your meals and snacks and how often you eat.
Do not ‘eat for two’.
● Eat a low-fat diet. Avoid increasing your fat and/or calorie intake. Eat as
little as possible of the following: fried food, drinks and confectionary high
in added sugars, and other foods high in fat and sugar.
● Eat fibre-rich foods such as oats, beans, lentils, grains, seeds, fruit and
vegetables as well as wholegrain bread, brown rice and pasta.
● Eat at least five portions of a variety of fruit and vegetables each day, in
place of foods higher in fat and calories.
● Always eat breakfast.
In general you do not need extra calories for the first two-thirds of pregnancy and it
is only in the last 12 weeks that women need an extra 200 kilocalories a day.
Trying to lose weight by dieting during pregnancy is not recommended even if you
are obese, as it may harm the health of your unborn baby. However, by making
healthy changes to your diet you may not gain any weight during pregnancy and
you may even lose a small amount. This is not harmful.
3
Exercise
Your midwife should ask you about how physically active you are. You may be
given information and advice about being physically active as this will be a benefit
to your unborn child.
● Make activities such as walking, cycling, swimming, low impact aerobics
and gardening part of everyday life and build activity into daily life by taking
the stairs instead of the lift or going for a walk at lunchtime.
● Minimise sedentary activities, such as sitting for long periods watching
television or at a computer.
● Physical activity will not harm you or your unborn baby. However, if you
have not exercised routinely you should begin with no more than 15
minutes of continuous exercise, three times per week, increasing gradually
to 30 minute sessions every day. A good guide that you are not overdoing it
is that you should still be able to have a conversation while exercising.
An increased dose of folic acid
Folic acid helps to reduce the risks of your baby having a neural tube defect. If
your BMI is 30 or above you should take a daily dose of 5 mg of folic acid. This is
a higher dose than the usual pregnancy dose, and it needs to be prescribed by a
doctor. Ideally you should start taking this a month before you conceive and
continue to take it until you reach your 13th week of pregnancy. However, if you
have not started taking it early, there is still a benefit from taking it when you realise
you are pregnant.
Vitamin D supplements
All pregnant women are advised to take a daily dose of 10 micrograms of vitamin D
supplements. However, this is particularly important if you are obese as you are at
increased risk of vitamin D deficiency.
Venous thrombosis
Your risk for thrombosis (blood clots in your legs or lungs) should be assessed at
your first antenatal appointment and monitored during your pregnancy. You may
need to have injections of low molecular weight heparin to reduce your risk of
blood clots. This is safe to take during pregnancy. For more information, see
RCOG Patient Information: Reducing the risk of venous thrombosis in pregnancy
and after birth.
Gestational diabetes
You should be tested for gestational diabetes between 24 and 28 weeks. If your
BMI is more than 40 you may also have the test earlier in pregnancy. If the test
indicates you have gestational diabetes, you will be referred to a specialist to
discuss this further.
4
Monitoring for pre-eclampsia
Your blood pressure will be monitored at each of your appointments. Your risk of
pre-eclampsia may be additionally increased if you are over 40 years old, if you had
pre-eclampsia in a previous pregnancy or if your blood pressure is high before
pregnancy.
If you have these or other risk factors, you may need to attend hospital for your
appointments and your doctor may recommend a low dose of aspirin to reduce the
risk of developing high blood pressure.
Additional ultrasound scanning
Having a BMI of more than 30 can affect the way the baby develops in the uterus
(womb) so you may need additional ultrasound scans. You may also need further
scans because it can be more difficult to check that your baby is growing properly
or feel which way round your baby is.
Planning for labour and birth
Because of these possible complications, you should have a discussion with your
obstetrician and/or midwife about the safest way and place for you to give birth. If
you have a BMI of 40 or more, arrangements should be made for you to see an
anaesthetist to discuss a specific plan for pain relief during labour and birth.
These discussions may include:
Where you give birth
There is an increased chance of your baby needing to be cared for in a special
care baby unit (SCBU) after birth. If your BMI is 35 or above, you will be
recommended to give birth in a consultant-led obstetric unit with a SCBU. If your
BMI is between 30 and 35, your healthcare professional will discuss with you the
safest place for you to give birth depending on your specific health needs.
What happens in early labour
If your BMI is over 40, it may be more difficult for your doctors to insert a cannula
(a fine plastic tube which is inserted into the vein to allow drugs and/or fluid to be
given directly into your blood stream) into your arm. Your doctors will usually insert
this early in labour in case it is needed in an emergency situation.
Pain relief
All types of pain relief are available to you. However, having an epidural (a regional
anaesthetic injection given into the space around the nerves in your back to numb
the lower body) can be more difficult if you have a BMI over 30. Your anaesthetist
should have a discussion with you about the anticipated difficulties. He or she may
recommend that you have an epidural early in the course of labour.
5
Delivering the placenta (afterbirth)
An injection is normally recommended to help with the delivery of the placenta
(afterbirth) to reduce the risk of postpartum haemorrhage (heavy bleeding).
What happens after birth?
After birth some of your risks continue. By working together with your healthcare
professionals, you can minimise the risks in the following ways:
Monitoring blood pressure
You are at increased risk of high blood pressure for a few weeks after the birth of
your baby and this will be monitored.
Prevention of thrombosis
You are at increased risk of thrombosis for a few weeks after the birth of your
baby. Your risk will be re-assessed. To reduce the risk of a blood clot developing
after your baby is born:
● Try to be active – avoid sitting still for long periods.
● Wear special compression stockings, if you have been advised you need
them.
● If you have a BMI of 40 or above, you should have low molecular weight
heparin treatment for at least a week after the birth of your baby -
regardless of whether you deliver vaginally or by caesarean section. It may
be necessary to continue taking this for 6 weeks.
Test for diabetes
For many women who have had gestational diabetes, blood sugar levels return to
normal after birth and medication is no longer required, but you should be re-tested
for diabetes about 6 weeks after giving birth. Your risk of developing diabetes in
later years is increased if you have had gestational diabetes. You should be tested
for diabetes by your GP once a year.
Information and support about breastfeeding
Breastfeeding is best for your baby. It is possible to breastfeed successfully if you
have a BMI of 30 or above. Extra help should be available if you need it.
Vitamin D supplements
You should continue to take vitamin D supplements whilst you are breastfeeding.
Healthy eating and exercise
Continue to follow the advice on healthy eating and exercise. If you want to lose
weight once you have had your baby, you can discuss this with your GP.
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Planning for a future pregnancy
Reducing your weight to reach the healthy range
If you have a BMI of 30 or above, whether you are planning your first pregnancy or
are between pregnancies, it is advisable to lose weight. If you lose weight, you:
● increase your ability to conceive and have a healthy pregnancy
● reduce the additional risks to you and your baby during pregnancy
● reduce your risk of developing diabetes in further pregnancies and in later life.
If you have fertility problems it is also advisable to lose weight, since having a BMI of
more than 30 may mean you would not be eligible for fertility treatments such as IVF.
Your healthcare professional should offer you a structured weight loss programme.
You should aim to lose weight gradually (up to about 1 kg or about 1 to 2 lbs a
week). Crash dieting is not good for your health. Remember even a small weight
loss can give you significant benefits.
You may be offered a referral to a dietician or an appropriately trained health
professional. If you are not yet ready to lose weight, you should be given contact
details for support for when you are ready.
An increased dose of folic acid
If you have a BMI of 30 or above, remember to start taking 5 mg of folic acid at
least a month before you start trying to conceive. Continue taking this until you
reach your 13th week of pregnancy.
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Sources