Maids and women health

I have a small consultation chamber at my residence.It is abuzz with activities of Pregnant females,their husbands and at times Sasu maas on Monday and Friday evenings when I don't have an evening OPD at Max.Mamta my super efficient house keeper doubles up as my receptionist as well.So many times I thought of employing a secretary but had to drop the idea as never got an approval from Mamta.
Now having a decent maid in Gurgaon is a real problem.These pregnant females who prefer to come to my clinic instead of Max Gurgaon very quickly realize the potential of mamta.They defer the counselling with me for a few minutes as they are desperately asking her for a maid.Some of them are so desperate to the embarrassment of their poor husband's they try to Poach Mamta as well as Dulal my driver.I can understand for a working lady who would be a mother very soon......poaching a maid is the most integral part of her health care.What if it is from  her doctors place?These Ladies are willing to pay any crazy sum of money........
Thank God.....Mamta is sensible.She values the money as well as the love,affection and freedom she gets at my place and that  insures that my health remains in order.She giggles and tells me the exploits off all my patients who have tried to poach her.Now courtesy Mamta.I have Rupa as well at home......And dulal the driver is being paid double the salary of local Gurgaon driver.So dear patients....next time you make a visit please please don't try to imbalance my health..........It is very important that I should be in a good health to take care of you ladies :-)) !!

Breast Crawl - Baby's First Meal

Step 4 - Ten Steps to Successful Breastfeeding

Ten Steps to Successful Breastfeeding - UNICEF/WHO Baby-Friendly Hospital Initiative (BFHI) - The Mother and Child Health and Education Trust

Ten Steps to Successful Breastfeeding - UNICEF/WHO Baby-Friendly Hospital Initiative (BFHI) - The Mother and Child Health and Education Trust

Breast Abscess,a Gynaecological perspective

I am writing this post on Dr Shalabh Mohan i.e, my husband's suggestion.It happens not infrequently when one of my postnatal patients contacts me when a mastitis has already turned into a breast abscess.I promptly refer them to Shalabh ,not just because of my relationship with him but because he surely is one of the finest surgeon I have come across.

His treatment for Breast abscess is Incision and drainage.The incision can be circumferential or radial as the situation demands.He prefers that breast secretion should be stopped from the operated breast to prevent fistula andto help proper healing.Now Ipsilateral suppression of breast milk is impossible which simply means writing cabergoline for an anxious and emotional mother who doesn't want to stop feeding her few week old baby

.Now this is the point where he wished me to check what our books or literature has to say.
In fact there was no clarity on suppression of milk production.One study in Turkey ( I actually don't know the size of it) found that needle aspiration of pus under ultrasound guidance gave same results as I and D.It is also mentioned that milk shouldn't be fed from the affected breast.But none of my books commented whether that means suppression or not.So,Dr Shalabh you can carry on with what your surgical books have to say.

Mastitis is the precursor of abscess ,and it can be easily controlled by antibiotics.Initially there is some inflammation in nipple and areola which causes obstruction in milk flow.An obstructed milk duct gets infected and causes mastitis.If proper antibiotic coverage isn't given at this time it leads to abscess.At this stage breast feeding should not be stopped from the affected breast ,as it is supposed that feeding helps in clearing of infection from the affected ducts.
Finally.........I think I am not very good at counselling Ladies regarding Breast feeding.UNICEF as come out with 10 steps which helps in minimizing the problems related to breast feeding and to make it a pleasant experience for mother and baby both.Will go through it and let me see if that helps!!

TLH part 5

TLH Part 4

Part 3 of TLH

Part 2 of TLH

Unedited video of TLH in case of Bladder Adhesions

What Follows in 5 posts are unedited video clippings of a female who had Total lap Hysterectomy for highly symptomatic Adenomyosis.She wasn't willing to try Mirena and was on Oral Progesterone since last couple of years.She had Previous 2 LSCS.Though technically not a very challenging case due to relatively not so big size of the uterus,bladder dissection was important.She had a badly adherent bladder.She was discharged the next day of her Surgery.

Lost 30 years of life instead of a 15 minutes surgey

Yesterday Operated on a Lady with prolonged History of leakage of urine since ages now,
Next day of the surgery she commented.''I can't believe that I wasted my 30 years for just a 15 minutes surgery''.Felt emotional and had a sense of gratification.Here s one person whose life will change 180 degrees Her surgery was TVTO.........a very simple urogynaecological procedure.

Quite a few gynaecologists who visit Max as Visiting consultant wished to know from my associates if I do it myself or call a urosurgeon ? In this stage of   my competence a urologist is not required by me,
But at the beginning you can surely take help from a urologist if you wish to learn.One surgery which gives me maximum satisfaction.........more than TLH.Here the patient who otherwise is absolutely fit comes out of adult nappies and diapers.They start enjoying their life,

I learnt it from a gynaecologist Mr Klazinga.In fact am planning to talk with Dynamesh people to start a preceptorship Programme where in fact I can teach the anatomy and physiology of the TVTO

Pregnancy folder

With an easy access of Internet people are quite well informed about the conditions they have been diagnosed with and in fact I find it quite helpful from a doctors perspective.I don't have to do much counselling as for most of the gynaecological conditions as they are already 75 % informed.
But Pregnancy is a totally different ball game.Young couples try to google out every possible keywords associated with Pregnancy and imply all of it on themselves.It causes a lot of confusion,restless nights,unnecessary visits to the doctor and of course unnecessary phone calls as well to the doctor.

In an attempt to overcome this problem I have come out with a Pregnancy folder for all my patients .This folder contains the answers to almost 225 FAQs,a diet chart,a exercise plan,antenatal Progress card ,list of investigations, patient information leaflet on Instrumental delivery and caesarean section.
I would request you to read your folder sincerely.I still get calls from my patients about the answers already enlisted in the folder.I have done some hard work for you and request you to help yourself by going through these questions.
PS : In future if you ask me a question  answered in the folder I will not repeat the answers to you and will just recommend to read the folder.Hope that will save both of us with lots of constructive energy.
If I come across new questions from you I shall update it in the new printouts of the folder.

Dermoid Cyst of Ovary

Big Ovarian Dermoid

Tuft of hair

Fat and sebum inside the cyst

Fat and sebum

Healthy contralateral Ovary

Early Pregnancy Bleed

Complications occur most commonly during the first trimester of the Pregnancy.Sorry it negates your mom in Law's theory that the 7 month is most crucial.BTW why is 7th month crucial?Anyone has any answers??
Mostly in pregnancy the complications are bleeding,pain or both.
Vaginal bleeding takes place in 20 % of  clinically diagnosed pregnancy.
Almost 15 to 20 % of clinically recognized pregnancy end in miscarriage.
With a bleeding in 1st trimester the following prognosis is expected

• 30 % will miscarry
• 10 to 15 % will have ectopic pregnancy
• 0.2 % will have hydatiform mole.
• 5% of the women will terminate the pregnancy
• The remaining 50 % will continue beyond 20 weeks.

Scary but true!!And that is also the reason after one miscarriage one should not loose one's heart as Pregnancy is a wasteful process and pregnancies which pass the stringent quality control test of nature reach upto term with a successful outcome.

Coming out of size O BLUES.....

By working risk 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. You should aim to:

• Base your meals on starchy foods such as potatoes, bread, rice and pasta, choosing wholegrain where possible
•  Do not ‘eat for two’Watch the amount you eat and don't get angry if your partner stops you from a big meal
• Eat a low-fat diet.Eat very little: 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 and 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 200kcal a day.   

Don't lose weight by dieting during pregnancy 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.

Exercise

Don't dismiss your doctor by saying that you exercise quite a lot as you have to walk at the work place .   

• Activities like walking, cycling, swimming, low impact aerobics and gardening are good form of recreational exercise.climb stairs instead of the lift.
• 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

t. 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. Ideally you should start taking this a month before you conceive and continue to take it until you reach your 13th week..

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) is 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.

Gestational diabetes

A oral Glucose tolerance test with 75 gms glucose and with 3 samples is performed between 24 to 28 weeks to detect gestational diabetes and if detected you will be referred to a diabetologist. 

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.

A low dose aspirin  reducesthe 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  about the safest way of delivery. 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 (NICU) after birth. .

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.

Delivering the placenta (afterbirth)

An injection is normally recommended to help with the delivery of the placenta (afterbirth) to reduce the risk of post partum 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 six 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 six 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. 

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
• You reduce  the additional risks to you and your baby during pregnancy
• You 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.

 

The woes of being Size O( not size 0)

Rather than a simple weight in Kgs or Lbs,a BMI (Body mass Index) is a better measurement of weight.The ideal BMI is 19 to 25.It is very simple to calculate and in these modern day smart phones you get plenty of apps which can calculate your BMI.

If you think that you are on the heavier side,check your BMI and if it is more than 30 you need HELP!!!!!!Don't shy away from taking that help.

Why should you take this help?For a lot many reasons,but here I will just mention those problems which you anticipate during Pregnancy

How can it affect you?

1. It increases the chance of blood clot formation(thrombosis) during Pregnancy.
2. You are more prone to develop Hypertension of Pregnancy or Pregnancy induced Hypertension which can complicate the Pregnancy badly.
3. Your risk of developing Gestational Diabetes increases manifold.
4. You are more prone to Vit D deficiency

How does it affect you baby?

1. Your baby has 3 fold increase risk of having neural tube defect
2. The risk of miscarriages increase by 5 to 10 %
3. The risk of still birth is more
4. Baby's are more likely to be more than 4 kgs,which shouldn't be taken as a compliment as a 'Healthy baby' in your case
5. These babies are at increased risk of diabetes and Obesity later in their life.

How does it affect the labour and delivery ?

1. The chances of preterm delivery increases
2. The labour can be quite prolonged,
3. You are more likely to end up with a caesarean section.
4. The caesarean section wound might take a longer time to heal.
5. Your caesarean section might be more complicated
6. There is increased risk of postpartum Hemorrhage (PPH) ie post delivery very heavy bleeding.

I think if you have a BMI more than 30 and if you are thinking of planning a baby this post might come across little depressing.If you say it hasn't depressed you then it would actually depress me.
I wish you to understand the downside of eating unhealthy.And no,not everything is lost.I wish to help you.I wish to see you through a healthy pregnancy and delivery and aftermath,but for that both of us need to be highly motivated.If you promise to cooperate,in my next post will talk about those methods and lifestyle if practiced preconceptionally can decrease the risk associated with your pregnancy immensely.