Always Choose your Teacher (Guru) Carefully

Today I attended a workshop on Urogynaecology.There was a live demonstration of a surgery called TVTO.A fairly simple surgery ,done nicely by the surgeon who was performing it.There was a small audience of local gynaecologists and Urologists,quite a few well known names as well.Many questions were asked,many questions answered during the surgery,though very nicely done........with the amount of questions and answers this surgery generated it sounded like quite a complicated and very demanding procedure.If I was a beginner,I would have been little scared to perform this surgery .

Let me share with you how I did my first TVTO.It was my first OT with Mr Derek Klazinga at Glan Clwyd Hospital,Rhyl.I was a trainee.There were three TVTOs posted for the day.He performed the first one.Then he asked me ,have you done one before?I said ,''No".His next question was,do you wish to do the next one and I jumped and said 'yes'!!.There it was .He kept on explaining me the procedure and in 20 minutes the operation was done and over.Goes without saying that he let me perform the third one as well.He made the surgery look so simple.

I was a registrar in India in 2000.There was this one consultant ,who would shout so much during the laparoscopic surgeries that I would get nervous and used to think Laparoscopy as the most difficult surgery in the world.In fact I was sure in my mind that never would I be able to perform laparoscopic surgeries.I reached UK ,with the same mindset and explained it to my Consultant Mr Tivy Jones and Dr Chris Clark.They encouraged me by saying, Mona ,it is not so difficult.Just imagine putting a niddle inside the abdomen to drain ascitic fluid.It is as simple as that.And very soon I was performing laparoscopies.They made it so simple.

Then once I was performing a diagnostic laparoscopy.There were quite a few omental adhesions.I got nervous.Mr Banfield,asked to proceed with the adhesiolysis.And I said ,I have never done it before.'Mona,there is always a first time for everything,remember'.And there I was performing ,my first adhesiolysis.

I had registered for my level 1 laparoscopy training with prof B lynch.It was meant to be a hands on diagnostic laparoscopy.But guess what?When I put the scope in,it was a big size Ovarian cyst.And I muttered again,I have never done a cystectomy before.And he said quite compassionately,but I am sure you will perform many more in future.This is just the first one.And to my own amazement,I had performed the first Ovarian cystectomy.

All of them were great Gurus.I was blessed to have met some great teachers in my life who made me realize life wasn't as difficult as it seemed if your approach was correct. 

Episiotomy........to have it or not??

I follow RCOG (london) Guidelines to the core in my day to day practice.And it works well for me and my patients.But there is one area where I personally am not convinced about the guidelines due to the clinical experiences.
It is recommended not to give a routine episiotomy.In UK as well, I was called by the midwives to repair big bad tears which I always believed a timely episiotomy could have saved.
Now ,In India  as ladies are googling a lot and read these Biritish and American books on Pregnancy,they also wish the 'cut' to be minimized or avoided.I try to do so,but recently it ended in fourth degree tear of one of my patients.The dreaded Complete perineal tear.I feel really sorry for the lady.There wasn't any high risk factor.A very easy 'lift off' ventouse delivery for foetal bradycardia in 2nd stage.The lady is obese but that doesn't increase the risk of CPT.
Took her to OT for the anorectal repair and the perineal muscle repair and the repair of anal spincter.This is day 3 of the delivery.She is doing Ok.But with CPT one expects problems only later.......a fistula or anal incontinence.I have done a satisfactory job as the surgeon and I hope with little bit of luck  she won't have these complications.Atleast that is my sincere wish.
But again I am debating whether it is a good practice to give routine cut in all the first time pregnant ladies.May be that is what i will do in future.

The Lady who had Dermoid in Pregnancy-Part 2

Sometime back I blogged about a Lady who I had operated upon for removing a big dermoid cyst while she was still pregnant.As ,at that point of time few of my friends were not sure whether I had done the correct thing by not terminating the Pregnancy,I promised you guys that I will update you about the outcome of this Pregnancy.
So 2 days back at 38 + weeks she was Induced for Labour as water surrounding the baby had decreased(moderate oligohydramnios,baby was mild IUGR,Umblical and Uterine artery showed higher than normal resistance and there were two tight loops of cord around the neck of the baby.She delivered a 2.5 kgs healthy male baby by ventouse delivery despite all the mentioned high risk factors and the  cord around the neck overhyped as and indication of caesarean section by Radiologists,gynaecologists and naturally patients alike.
That is not all.While she was pregnant her Downs Screening reports(double as well as quadruple) suggested her ,this Pregnancy to be a high risk for downs.She decided not to go for an amniocentesis as her astrologer told her that with a very strong Jupiter in her birth chart nothing will go wrong.That astrologer also had told her that it will be a vaginal delivery and it will be a male child.Amazing............
Planning to meet this amazing astrologer :)

Broadligament fibroid for TLH and Obturator fossa dissection

Need an answer from you......

It is a common occurrence.I get call anytime in night.11pm,12 MN......Patients having Problems.Pregnancy with bleeding ,pain etc.So,how can I reassure you that your Pregnancy is safe?By getting you examined.And for that I advice all such Patients to come to the Hospital emergency to be examined by the Junior consultant gynaecologist on call.
The moment I ask them to go to the Hospital emergency...........Typical question is....In the night Doctor?Is it so urgent,but the pain or bleeding or any XYZ complain is not so bad.If I persist.......if you find it an emergency enough to give me a call so late in the night or so early in the morning I think it is an emergency enough to be examined and they are really reluctant.
This is a mystery for me.What actually are your expectations from me?I would appreciate if any one of you, who had such experience with me,could please let me know that what are your expectations when you give me an emergency call if you don't wish to come to hospital in the night?Knowing your expectations will help me  serve you better!!

Are you a Diabetic Mom???

This month out of 20 patients whom I delivered , 3 were Diabetics on Insulin and 2 had a Gestational diabetes controlled on Metformin.We as Asians are more prone to diabetes.Our eating habits have changed drastically, not for good and Pregnancy itself is a diabetogenic state.India for sure is the diabetic capital of the world.

So ,what do we do?Should we panic.Not really.......but yes it needs a lot of commitment from the mom to be herself as well as the doctors taking care of her.One of these ladies who is a Insulin dependent diabetic shared with me that when she met an Obstetrician after she tested positive for pregnancy,the doctor gave her a horrified look.This lady had a mildly raised blood pressure and deranged thyroid function too.She was told that it was a very high risk pregnancy with a high probability of complications.That scared this lady and she ultimately landed under my care.

I do agree that these pregnancies complicated by medical conditions are challenging for physician and patient alike but it isn't some thing to panic about.Patients need to be realistic in accepting the condition and comply to what their doctor advises.At the same time we as a doctor  need to make the patients aware of complications of possible uncontrolled condition without scaring them.It is a fine balance between telling the truth and make it sound scary.

And how can I leave my all time favourite topic....Cesarean vs Vaginal delivery.......It never means that if you have diabetes you need to have Cesarean for sure.

Most of the Obstetrician have special interest in high risk pregnancy,but as a patient choose your doctors carefully,comply to their advise and I am sure you and your baby will be fine :))