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M A T R U D E V O B H A V

A
Ethical, Moral and Philosophical Aspects of
OBSTETRICS & GYNAECOLOGY
An Indian Perspective
By
DR R. ANJANEYULU, MD, DGO, FCPS
Emeritus Professor of Obstetrics and Gynaecology
B.J. Medical College and Sassoon Hospitals, Pune
Maharashtra State, India
Foreword by
Dr. K. Bhasker Rao, M.D., F.R.C.O.G., F.M.S.
Emeritus Professor of Obstetrics and Gynaecology
Madras Medical College
(Formerly Director, Institute of Obstetrics and
Gynaecology,
Govt. Hospital for Women and Children, Egmore,
Madras)
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R. Anjaneyulu; M.D., D.G.O.; F.C.P.S.
M A T R U D E V O B H A V A
Mother
The Universal Mother is in the form of
Bhoomata who bears all of us ! She is the Prakriti or
Shakti or energy without whom the world cannot
exist. She is the same Shakti in the form of
Goddess of Learning; Saraswati who helps Lord
Brahma to create this world; in the form of Goddess
Lakshmi; Goddess of wealth who helps Bhagwan
Vishnu to protect the world bestowing health,
happiness, prosperity and well-being of the people;
in Goddess Parvati; she gave Shakti or energy to
Lord Shiva to destroy the world.
She is the same Mother to whom we also pray
as Durga during Navaratri, to destroy the evil forces
and cut the knot of ignorance in our heart and also
the quality of Ahamkara in us and bestows upon us
knowledge and wisdom!
The Universal Mother has many other
manifestations in the form of Gayatri she protects
us; as Ganga Bhavani she gives us water for
survival; as Gomata (cow) she gives us milk for
health the nourishment and as Mother
Geeta (Bhagavadgeeta)whose door is open to any
one who knocks and seeks refuge in distress in her
bosom. Stree or Ammai is the incarnation of
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Shakti Swaroopa. Mother gives herself to the
development of the child and works hard and
sacrifices for the safety and survival of her children.
It is this spirit of Tyaga or sacrifice that makes the
value of motherhood great! In this world, no other
person deserves to be more respected than
MOTHER.
It is to the feet of all mothers of the world and
the Supreme Mother that offer my Pranam and
salutations while attempting to write this book.
SARVAMANGALA MANGALYE, SHIVE SARVARTHA
SADHIKE
SHARANYE TRIAMBAKE GAURI, NARAYANI
NAMOSTUTE
Oh Mother Durga, wife of Lord Shiva looking after
the welfare of everybody and fulfilling all the desires,
cherished by one and all, I am under your shelter
and offer my Namaskarams to you !
MOTHERS BENEDICTION
May you live long
May you live long blesseth me my mother,
Even as the shadows of death draw nigh,
In bed, a sinking soul, almost breathless,
Still she blesseth me - May you live long.
A mothers love who can fathom? In death agony
She blesseth - May you live long
It is her parting wish her legacy
To her son, in clear tone she says Live long.
Alas! She musters all her strength and says
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May you live long to give that benediction
Happiness enlivens her face; by that sweetest
Utterance, she makes the lord of death tremble.
To approach her, for who would bless her son
After she hakes off her mortal coil,
To bless live long its a mothers right!
She wants to control fate by her benediction.
This noble soul! This mould of sacrifice,
Mother Dear Amma who soothes all our pain,
Who begets, suckles brings up bears all woes,
Is she not the mortal symbol of God!
To worship thee, kiss the dust of the feet,
Is the greatest duty of a true son.
Not all the pomp and power of the world
Can rival the glory of the mothers love.
Almighty Lord who created this Treasure
A mothers heart so tender and divine
Who bears all suffering for her progeny
To me, O Lord! Thou art the True Mother!
Alas! As she slowly sinks, still in low
Accent says My child, may you live long!
All the riches of a mothers true heart
Her rich blessings, she showers as she parts.
May you live long!, a boon she gives outright
Live Long! the highest benison and grace,
Mother! Mother! Mother! Through all ages,
Thou art praised, For Mother is the Lord!
Written by my father Late Rebbapragada
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Subba Rao just before his mother (my
grandmother) passed away.
FOREWORD
Most medical books written by physicians are
meant for the benefit of the medical fraternity:
physicians, medical students, nurses or paramedics.
This book entitled Matrudevobhava extolling the
mother is written by a senior obstetrician of India
who has a vast experience both as a skilled clinician
and as a popular post-graduate teacher for over 40
years. Through this volume he not only brings out so
lucidly the scientific and technical aspects of
obstetrics and gynaecology as a whole but also
enlightens us with lot of his wit and philosophy (with
appropriate quotes from Adi Sankara to
Shakespeare and Sri Satya Sai Baba) on the social,
moral and ethical aspects of the problem of human
reproduction. To support some of his observations,
he cites liberally from the Upanishads the Geeta
and the Bible. He makes a strong case that the
mother who nourishes, labours, protects and gives
her all to her child (sometimes even sacrificing
herself in the process) deserves to be treated much
better than what she gets in our society today.
Though the exhortation Matrudevobhava (taken
from the Taittreya Upanishad) is to respect and treat
mother as God if only perhaps we given her right
from birth, love and affection, proper nutrition, and
education and the health care she needs in
reproductive years and after, to a small extent we
may be able to repay the enormous debt we owe
her.
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Dr. Anjaneyulu rightly warns that the line of
demarcation between physiology and pathology of
pregnancy and labor are not clear cut; and accidents
(or even tragedies) may be due to the neglect by her
family or her physician. Therefore, prenatal care and
vigilance during labor is quite essential. His brief
essays on sex-determination, sex-education,
abortions, family planning, normal and abnormal
menstruation, cancer of uterine cervix and
menopause are so succinct and educative that the
book will be useful both for medical and the lay
public. His warning to the profession and the public
about the alarming rise in the caesarean section and
hysterectomy rates should be heeded and reflected
upon.
He rightly emphasises that the obstetrician of
today should take the responsibility to supervise
womens health in the widest sense of the term
from childhood, through adolescence to menopause.
In India, over 100,000 mothers die annually due to
complications of pregnancy and childbirth. Most of
these deaths are preventable. When the Safe-
Motherhood has become the watch-word with UN
Agencies (like WHO, UNICEF) and the Government
of India, this book is most timely and educative to
promote the cause of womens health in our country.
(K. Bhasker
Rao)
9
th
August
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1994
Madras
PREFACE
In All His Dispensation God is at work for our
good
In Prosperity He Tries Our Gratitude
In Mediocrity, Our Contentment
In Misfortune, Our Submission
In Darkness, Our Faith.
Under Temptation, Our Steadfastness
And At All Times..
.Our Obedience and Trust In HIM.
How true it is that the Lord is at work for the
good of the universe in all His dispensations. For
the survival of the human race the Lord has
instituted several safeguards for pregnancy and
to make childbirth such a spectacular and
wonderful event. It is His Will and Blessings that
gynaecologist one can do his best but ultimately
it is only His rule which has the final say.
The discipline of Obstetrics and Gynaecology
clearly highlights the role of the mother, her qualities
to bear and forbear, persistence and perseverance
and the supreme sacrifice or Tyaga even at the
expense of her own health for the sake of progeny
and for bringing up of children. The foetus in its
manoeuvres during the birth process as well as after
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birth, has given the message of a code of conduct
and the Vedantic aspect of life. The gynaecological
conditions point out to the precepts handed over by
elders from times immemorial and to the conditions
that occur and are observed in everyday life. No
other branch of medicine teaches so many ethical
and moral values.
What I have learnt and imbibed all these years,
either while treating the patients or teaching
students, the good qualities I have observed from
everyone I have tried to present in this book in my
own humble way the message of the Lord.
It is not my intention to write a regular text-
book. As such, this book is meant not only for the
medical profession in every discipline and practising
doctors, but also for everyone including non-medical
persons as it concerns the ethical moral and
philosophical aspects of life. While so doing I have
dealt, to an extent with the technical part of the
subject in as simple a way for the easy
understanding of everyone. I have not gone beyond
the extent necessary to convey the message it
imparts. Each chapter is an entity by itself though
various subjects have been described.
Spiritual and moral teachings imparted by my
parents in my childhood and Mothers Benediction,
the poem incorporated in this book written by my
father, Late R. Subbarao and read to all our brothers
and sister, have had a lasting effect upon me. I am
ever grateful to my eldest brother Late R.
Ramananda Rao without whose encouragement and
financial assistance I would not be what I am today.
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It was my brother that handed over the above divine
message of the Lord to be observed and followed at
all times. Both my father and brother greatly
influenced my attitude and working in my life.
I have been greatly influenced by Late Swami
Chinmayananda whose inspiring lectures at the
Geeta Gyana Yagnas had a deep impact on my
outlook. In my own subject, I owe everything to my
teachers who taught me as a student and also in the
formative period of my training and to the writings of
great teachers like A.L. Mudaliar, R.K.K. Thampan,
M.K.K. menon, Ian Donald, Munro Kerr and J.
Chasser Moir, F J Brown, Johnstone and Eastman,
Joseph P De Lee and Greenhill, Profs Jeffcoate and
Wilfred Shaw, Keller, Novak and Joe V Meigs,
Dewhurst, Masani, Studd from whose books I have
learnt and taught my students. I have quoted these
authors without reservation in this book.
While invoking the blessings, of the Lord I want
to make it clear that this is not a religious book.
There is only one God Lord Almighty or Brahman.
Swami Sivananda described the diety Lord Iswara at
Kedarnath as having Formless Form. How true are
his words. The Lord has no form and all are his
forms as every one of us is the swarupa of the Lord.
He is most secular as he is the in the heart of every
body.
Sarvasya ca ham hrudi Samnivisto
(Geeta Chapter 15)
I am seated in the hearts of all.
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Call the Lord by any name, Allah, Jesus, Rama
or Krishna One is referring only to the Divinity.
Even the meaning of the words points to the same
divinity. The word Allah Al-Divinity, Lah to become
laya or merge in it; Similarly Jesus (Yesu) means Ye
One and Su Divinity. Rama constitutes three
components of sounds Ra Aa Ma. Ra signifies
Twam i.e. Brahma or Divinity, Ma signifies Twam;
i.e., Thou, the Jiva or the individual and Aa connotes
the kinship of identity of the two i.e., the Jiva and
Brahma. The Lord is also secular in that the
responds to anyone meditating on his name with
purity and devotion in any language or religion. Thus
Divinity is only one and the paths to reach Him are
different.
I have quoted quite often from the Divine
messages of Bhagvan Sri Satya Sai Baba in this
book including the above paragraph. His teachings
are so lucid and simple that even a lay man like
myself can understand and comprehend the
essence or core of what is written in Geeta,
Upanishads or Vedas. One sees in his preachings
a combination of Hindu concept of Vedic cosmic
awareness, the Islamic concept of Allah as universe,
the one who sustains us all and the Buddhist and
Christian compassion. Truly a great teacher and in
the real sense, Guru, (one who removes ignorance
from everyones mind). President Shankar Dayal
Sharma said that Bhagwans mission is to bring
change in Naitika, Dharmika and
Adhyathmic thoughts so that all of us strive to realise
our own true nature; i.e. That Thou Art. I pray and
seek Bhagwans Blessings in writing this book.
Acknowledgements
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While constraints of space does not permit me
to include the names of all my professional
colleagues, well-wishers and friends who have
inspired me to formulate my thoughts to make this
book possible, I would be failing in my duty if I do not
mention the enormous influence on my outlook and
thinking by at least some of them.
At the outset, I would like to pay my obeisance
to Late Dr (Mrs) PK Devi who as a senior colleague
encourage me from the very beginning of my
professional career.
Late Shri SAL Narayana Row, erstwhile
Chairman Board of Direct Taxes was always a friend
philosopher and guide to me. My brother-in-law, Dr B
Dayananda Rao, is not only an eminent
neurosurgeon but an erudite scholar of English
Literature. I have had the good fortune of his having
gone through the entire manuscript of this book and
the benefit of his advice.
Dr Banoo Coyaji has, since he time I came to
Pune been a source of great inspiration. A true
karmayogi, her pioneering work in all aspects of
maternal health and Safe Motherhood have
throughout been the cardinal example to follow.
I have gained immensely from the discussions I
have had with Pandit KL Gautam, a renowned
Sanskrit and Hindi scholar and Dr Padmakar Vartak,
who has an indepth knowledge and understanding of
our traditions, philosophy and medicine. Both of
them gave me valuable advice and information
which I have duly incorporated in the book.
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I have also had fruitful discussions with Doctors
Sudhikumar, Mrs Rajlaxmi, Mrs Asha Joshi and Mrs
Rashmi Gapchup. Mrs Jyotsna Apte had very kindly
undertaken to make the line drawings. Dr Nishikant
Shrotri and Dr Mrs Aparna Shrotri have given me
valuable help and advice in printing the book. My
grateful thanks to all of them.
I owe my gratitude to Dr K Bhaskar Rao,
Emeritus Professor of Obstetrics and Gyanaecology,
Madras Medical College and Formerly Director,
Institute of Obstetrics and Gynaecology, Govt.
Hospital for Women and Children, Madras, an
internationally renowned gynaecologist and author of
several books, for having consented to write the
Foreword and giving me several valuable
suggestions.
Last but not the least, I have to acknowledge
the support and cooperation I received from my wife
R Krishnaveni, who has been the true inspiring force
behind writing this book.
MATRUDEVOBHAVA
CONTENTS
Chapters
1. Intricate Role of Nature in the
Survival of Mankind
21
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2. Pregnancy Essentially a
Physiological Process
32
3. The Foetus can listen and react
from Mothers Womb
42
4. Anaemia in Pregnancy 49
5. Abortion Problem 59
6. Onset of Labour Still an Enigma 70
7. Labour Hard Work on Part of the
Mother
78
8. Shortest & Arduous Journey in Life 85
9. Vagaries of Uterine Contractions
during Labour
90
10. Baby in the Womb My Guru 98
11. What do the First Breath and Cry
of Baby Indicate
104
12. Still Births and Neo-natal Deaths
Duty of the Obstetrician
108
13. Each Pregnancy and Childbirth
Rebirth for the Mother
111
14. Pre-Pregnancy Care The Need
of the Day
115
15. Breast Feeding 119
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16. Sex Determination and Sex
Differentiation
125
17. Ethical Aspects of Induced
Abortion
136
18. Infertility 148
19. A I D Adoption : Ehical
Consideration
157
20. Ethical Problems IVF & Surrogate
Mother
167
21. Hormones in Normal and
Pathological Conditions
172
22. Amenorrhoea 176
23 Dysmenorrhea 182
24. Endometriosis 186
25. Genital Prolapse 191
26 Ovarian Tumours 197
27. Cancer of Cervix 201
28. Diseases of Urinary System 206
29. Premenstrual Tension 210
30. Menopause 212
31. Cancer of Breast 217
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INTRICATE ROLE OF NATURE IN THE SURVIVAL
OF MANKIND
Conception occurs at the outer end of the
fallopian tubes and after passing through various
phases of development the fertilized ovum gets itself
implanted into the endometrium (mucosa lining
uterine cavity) at the upper part of the womb after 6
- 7 days. From then on the embryo grows up to 40
weeks of gestation into a fully grown child.
All human beings get their genetic and
chromosomal material both from father and mother.
But the baby is developing in the uterine cavity of the
mother. Hence the baby has some antigenic material
in it which is foreign to the mother. Such a foetus is
regarded as Graft attached to the mothers womb
by he umbilical cord and placenta and the mother is
called Host.
It is a common phenomenon that when a graft
with different antigenic make up is implanted the
32. Sex Education 222
33. Family Planning 227
34. The Womb A Saga of Ecstasy
and Sacrifice
237
35. The Obstetrician and
Gynaecologist Trimurti or
Dattatreya
246
36. Epilogue 253
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response in the host is cell mediated. Antigens from
the graft are taken up by tissue macrophages
processed in the reticulo-endothelial system and are
presented to the immune system of the mother
consisting of two types of cell lines 1. T-cells 2. B-
cells.
T-cells reach the graft via the blood stream,
invade it, attract phagocytes by secretion of
lymphokines and initiate graft destruction. B-cells on
the other hand produce antibodies LGM, IGA and
IGG in the host.
Such a type of graft destruction is expected in
all pregnancies. In each pregnancy mother and
foetus are exposed to over an area of 10-15 sq.
meters of placental surface to each others
potentially foreign antigens. Each pregnancy should
have ended either in abortion, retardation of foetal
growth or even intrauterine death of the foetus. Yet
the baby survives and at birth there is no evidence of
graft rejection.
Two major blood antigens are present in
humans (1) ABO and Rh (2) HLA-Human Leucocyte
Antigens. Antibodies (both cellular and humoral) are
produced in mother for both and with each
pregnancy and delivery the antibody titre is
increased especially for the human leucocyte
antigens, and yet no damage occurs to the next
pregnancy. Even today grand multiparity of 8-10-12
is common in certain countries (one patient even
delivered a twenty-third child), and these women
deliver full term healthy babies.
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In short, even though the baby is developing in
a immunologically hostile environment yet the baby
escapes immunological rejection what is it that is
protecting the baby?
Many scientific explanations have been given to
show that at every stage of development of the baby,
Mother Nature is protecting it.
(a) Role of Zone Pellucida : Immediately
after conception the fertilized ovum till it gets
implanted in the uterine cavity is protected by a
thick membrane Zone Pellucida.
(b) Role of Uterus or the Womb :
Mother nature has created uterus or the
womb as the ideal place for implantation and
continuation of pregnancy. One often wonders
what would happen if the pregnancy occurred
in other organs. Experiments have shown that
such pregnancies have been rejected. It is the
only one organ that can grow and expand to
such a size to accommodate the fully grown
baby at term and return back to its normal size
after delivery. Even the location of the womb is
in the bony basin of the pelvis so that it is
well protected from any trauma especially in
the vulnerable early period of pregnancy. At
the time of delivery with the bony pelvis it
forms a birth canal so that the baby passes
through easily in its travel from the uterine
cavity to the outside world. Hence the uterus is
called the most privileged site for the
continuation of pregnancy.
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(c) Barrier between maternal circulation and
foetal circulation: To minimize the antigen
antibody reaction, the foetal circulation and
maternal circulation though very close to each
other in humans, do not usually mix because of
the placental barrier. However leaks do occur
in the barrier, the foetal red cells may be seen
in maternal circulation as early as 8
th
week of
gestation. But there is lack of transfer of
maternal leucocytes into the foetus (even if it
occurs that is very occasional) and this is
also a major factor in protecting the foetus by
maternal immune action.
(d) Role of the Mother and the Foetus:
Changes occurring in maternal circulation in
pregnancy namely lymphopenia and increased
production of adrenal steroids, ovarian and
placental hormones oestrogen,
progresterone and chorionic gonadotrophic
hormone all these exert an immuno-
suppressive activity in the mother and help in
the continuation of pregnancy. The foetus in
turn is immature and does not express its
antigenicity for quite sometime in the intra-
uterine life.
Apart from the above many interesting
phenomena occur at the time of the implantation of
the fertilized ovum into the decidua or mucosa lining
the uterine cavity. All round the fertilized ovum a
structure called trophoblast (also amed chorion) is
developed which when fully grown forms the
placenta and is responsible for the nutrition and
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welfare of the growing foetus inside.
These trophoblastic cells in the process of
embedding into the uterine cavity destroy the
decidua, form a pool of blood in which the ovum
bathes and this is limited to the base of decidua.
Here both the trophoblast and decidua play a very
crucial role.
In the decidua at this time, there are large
granular lymphocytes of maternal origin. These
belong to the natural killer type of T-cells. In normal
course of events these decidual lymphocytes would
have destroyed the implanting of fertilized ovum by
producing cellular immune reaction. Yet they do not
do it. This is because they do not recognise the
trophoblast as a foreign antigen and see in it their
self, think that it is one of their own and hence do not
destroy it. On the other hand they help in limiting the
trophoblastic invasion so that implantation occurs
properly. The trophoblast also controls its own
invasiveness. Other wise the ovum would have dug
its own grave in the process of implantation.
Immunological Tolerance
Trophoblast is of foetal origin and has antigens
of paternal type. In the blood flowing through the
chorio-decidual space there are both foetal cells
from the trophoblast and the maternal cells. Yet the
antigens on the trophoblast are either masked, shed,
or modified at the cell surface and do not express
their antigenicity. On the part of the mother (as
described above) the maternal cells in decidua do
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not produce immune response in spite of the
production of the specific antibodies (humoral or
cellular).
In short, maternal cells and foetal cells develop
tolerance to each other and this is classically known
as Immunological Tolerance of Pregnancy. In this
way no antigen antibody reaction occurs thereby
preventing rejection of the graft foetus by the host
mother, which in fact accepts the foetus.
Immunological Enhancement.
The other important phenomenon that occurs in
normal pregnancy is that the humoral antibodies
(LGG) unite with the helper T-cells and blocks and
protects the placental antigens and renders them
immune from the T-cells (killer cells) attack. These
antibodies are known as blocking antibodies and the
phenomenon as Immunological Enhancement. Such
protection from blocking antibodies is not observed
in abnormal reproductive states like abortion or
toxaemias of pregnancy.
Surrogate Mother
A Mother takes upon pregnancy in her womb
where the ovum and sperm of two different people
are fertilized outside and later implanted in the
uterus of the surrogate mother. Here the antigens
are foreign both from the paternal and maternal side.
Yet even in these (mother) the uterus accepts the
pregnancy without rejecting it and takes it to term.
If one ponders over conception, implantation
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and continuation of pregnancy, one cannot but
wonder that the impossible has occurred. All
scientific explanations can only take us to that extent
to say that on one side foetal antigens do not
express antigenicity and the mother does not
produce immune reaction by the antibodies. But the
why of it seems beyond the scope of science; why
should nature do like that? Is not nature violating its
own laws? (violating the laws that are made is the
prerogative of the present day administration. Some
people preach laws only to be observed by someone
else but the laws do not apply to them). No one can
explain. This is where science ends and spirituality
begins. It is all done by the handy work of the Lord
Almighty. The Maya of the Lord Vishnu so that
the human race survives.
Preservation and welfare of not only human
beings but also life at lower levels does not
escape the attention of God. Even the most
stringent laws of physical nature are
compromised in the process. The best example
one can think of is the fact that contrary to the
normal effect of cold contracting bodies, cold
below 4 degrees centigrade expands the volume
of water so that the resulting solid ice even
icebergs float rather than sink to the depth by
their weight. God, in his benignity, so relaxed the
law of nature to save the marine life underneath
which would otherwise be crushed under the
very weight of the sinking blocks of ice. Can
there be a greater wonder!
In the protection and survival of the human
race, the Lord has taught one important lesson; i.e.
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Tolerance and Acceptance. Unfortunately one does
not see this trait in day to day life. People cannot
tolerate one another even for very small things. If
one is coming up in life others do not tolerate it and
in turn they develop jealousy and hatred. All of us
are Swarupa of the Lord any wrong one does to
another is in effect doing wrong to himself. As in
immunological enhancement for he common good of
continuation of pregnancy, helper T-cells join hands
with immune antibodies to protect the placenta from
immune attack from the killer T-cell. In short, for any
good purpose which is meant for the welfare of
mankind everybody should forget their differences
and work together.
One feels sad to read every other day in the
newspapers regarding a daughter-in-law being
tortured by the in-laws; either she is being driven to
commit suicide by hanging or burning herself or she
is forcibly killed by the in-laws for not getting enough
dowry etc. In many more cases, though not to the
same degree, constant harassment is the rule; being
insinuated by every one in the house, she is being
treated as an alien or foreign from the immunological
point of view i.e. as a graft only to be killed by the
killer cells and to be discarded or rejected.
Every one should learn a lesson from what
mother nature is doing to preserve mankind. The
fertilized ovum could have been easily killed or
thrown away at the time of implanatation. Uterine
large granular lymphocytes do not show any immune
reaction and accept the ovum and the trophoblast.
After all, the daughter-in-law is also a daughter in
someone elses house and she should be treated as
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their own daughter in the in-laws house. It is this
initial acceptance of the daughter-in-laws that
reflects later in life the attitude of the daughter-in-law
towards her in-laws. If only the attitude of tolerance
and acceptance is observed in any home then only
there will be happiness prosperity and above all
peace in that house.
Even our religion and Vedas stress the same.
In Atreya Upanishad it is written that woman accepts
the sperm as its own body and the sperm also
accepts the womens body as its own body.
Swami Vivekananda in his address to World
Parliament of Religions (Sept 11
th
1983) exhorted I
am proud to belong to a religion which has
taught that world both tolerance and acceptance.
We believe not only in universal tolerance but we
accept all religions as true.
While it is true that all religions preach
tolerance yet, today there is just enough religion
to hate each other.
Bhagwan Sri Satya Sai Baba in his Divine
message said Peace and Truth are our own
swarupa. To know one self is truth and to enjoy one
self in the bliss is ananda. Every thing good or bad
depends upon our own behaviour. If it is in the right
direction then only Krishna will give us happiness.
For all these we must take Sahana or tolerance as a
holy and powerful weapon. It is because
Dharmaraja took this tolerance as a weapon that he
could achieve success.
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Tolerance should not be taken as weakness or
cowardice but should be seen and observed in its
true sense. The power and shakti present in sahana
one cannot see in any other weapon. However,
sahana should be observed not just in an individual
but in a collective form. That is why Vedas start with
Sahana Vavatu, Sahanau Bhunaktu. Let us grow up
together, let us live together, there should not be
jealousy, kalaham or fights or misconceptions
among people. Everyone should live harmoniously
and happily as children of one mother.
Lastly, even so-called very bad and cruel
people do have in them a spark of divinity which is
clearly shown in the part played by T-killer
lymphocytes at the time of implantation of the ovum.
They preserve and protect the ovum instead of
destroying it. As Bhagwan Sri Satya Sai Baba says
From a hunter one can transform one self to
Maharashi Valmiki with the kripa of the Lord if one
adopts to this holy and powerful weapon of Sahana
(or Tolerance and Acceptance).
PREGNANCY
ESSENTIALLY A PHYSIOLOGICAL PROCESS
(DIVINE NATURE DOES EVERYTHING FOR THE
WELL BEING OF
the Mother AND BAbY)
Certain physiological and anatomical changes
occur in the mother as a consequence of pregnancy.
They are a temporary adaptation and revert back to
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normal after delivery and purperium and produce no
deleterious effects on the mother. If the mother is
healthy and adequate nutrition is maintained, these
changes are not a strain on mothers well being.
Many women in fact feel better and happy in
pregnancy. These changes start occurring very early
in pregnancy and are a positive adaptation and
precede any positive demands of the foetus.
The implantation of the fertilized ovum is
usually in the fundus of the uterus and this is
facilitated by the action of the hormone progesterone
which acts like physiological sphincter on the circular
muscle fibres of the isthmus and cervix. This
sphincteric action may be of importance to restrain
the ovum and the growing embryo within the uterus
and also help continuation of pregnancy to term.
Sufficient production of this hormone is ensured by
the corpus luteum of pregnancy which in turn is
maintained by the chorionic gonadotropic hormone
produced by trophoblast which is all round he
fertilized ovum.
The non pregnant uterus is geared up by
increase in size and weight to contain and
accommodate the products of conception. Its
musculature undergoes hypertrophy and
hyperplasia, progressive softening occurs, and the
arrangement of the musculature helps in the
fulfilment of two objectives:
Formation of the Parturient Canal during
labour for the easy descent of the foetus and
secondly the all important control of bleeding
after delivery i.e. post partum haemorrhage. It
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is achieved by the contraction and retraction of
the muscle fibres of the upper segment of the
uterus as well as the inter-lacing fibres of the
uterine musculature which go as figure of 8
round the blood vessels at the placental site
and act as living ligatures.
Prevention of infection: The genital tract
is rightly divided into three compartments
during pregnancy. The uterus containing the
foetus, liquor and membranes is the aseptic
cavity or compartment. No infection can
ascend to the uterine cavity as the cervical
canal is blocked by a thick plug of mucous
produced by the proliferative cervical glands
and this plays a vital role.
The upper part of the vagina is the antiseptic
compartment, the vaginal discharge is highly acidic
(pH varying from 3.5 to 6) because of production of
lactic acid as a result of the glycogen in the epithelial
cells being acted upon by the Doderleins bacillus.
The lower part of the vagina and the vulva
contain all saprophytes and pathogenic organisms
this is called the septic tract.
It is amazing that in the process of delivery the
foetus comes from the aseptic cavity through the
antiseptic tract and later through the septic tract in its
journey to the outside world. Nature is not content
with that. Before the birth of the baby the bag of
water in front of the baby ruptures so that organism
at the vulva and vagina are washed out. After the
birth of the baby the liquor comes out in a gush and
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finally the after birth (or) the placenta mops up all the
organisms as it comes out.
While this is so with nature the obstetrician (if
proper care and antiseptic and aseptic precautions
are not taken), can cause pelvic infection. Any
examination during delivery or any operative
procedure causing trauma to the genital tract
predisposes to pelvic infection as all these carry
infection from septic tract through antiseptic and
ultimately to the aseptic cavity.
Mother nature has also seen that the baby is
surrounded all the time in the uterine cavity by
amniotic fluid. This fluid, during pregnancy, serves
several important functions. It provides a medium in
which the foetus can freely move, cushions the
foetus against any possible injury, helps to maintain
an even temperature and not the least, it provides
useful information to the doctor regarding health and
matuity of the foetus.
The Maternal Internal Environment is Altered to
Create Conditions favourable to the Foetus and the
Changes are in Apparent Excess of the Needs of the
Foetus.
(a) The blood volume is increased during
pregnancy. Plasma volume increases by 45%
upto 1250 ml in primigravida and 1500 ml in
multigravida. Increase of red cell mass occurs upto
400 ml (18%) in women given iron supplements
and 250 ml when not given iron supplements.
The blood volume increase is essential to
maintain uteroplacental circulation and the
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haemodilution caused by the increase of
plasma volume causes less of blood viscosity
and the peripheral resistance is reduced, which
in turn helps to keep the blood pressure under
check. From a teleogical point of view if by any
chance there is loss of blood after delivery
more plasma is lost and the haemoglobin and
red cell reserves are not affected.
The cardiac output is increased by between
27 64% far more than necessary to provide
for the increased blood flow to the uterus,
breast and other organs. Even the renal blood
flow is show to be increased to as much as
50% as early as ninth week of gestation.
Maternal hyperventilation is a normal
feature of pregnancy. This lowers the PCO2
in the maternal arterial blood. This lowered
partial pressure of CO2 in the blood on the
maternal side of the placenta then facilitates
the transfer of CO2 from the foetus t the
mother. Also, instead of preserving milieu
interior which is the most common
endeavour of the body in all other situation,
the physiological adaptation of the mother
creates a constant changing environment
appropriate to the successive changes of
pregnancy and to provide conditions most
favourable for the growth and development
of the foetus.
The mother accumulates fatty reserves in
anticipation of the future needs of the
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foetus. 4Kg of fat is deposited in the anterior
abdominal wall back and thigh. This stored
fat provides energy which may be needed in
late pregnancy, labour and puerperium and
in cases of nutritional deprivation.
Changes in the breast include growth and
proliferation of the glandular and duct system
and half-way through the pregnancy, secretion
of colostrum begins. The breasts are thus
anatomically and physiologically prepared to
take on the task of lactation and of supplying
the infant with milk and essential nourishment
once it is delivered.
ROLE OF THE PLACENTA
Placenta has diverse functions during
pregnancy apart from production of hormones
essential for continuation of pregnancy. Its main role
is in maintenance of nutritution of the foetus. A
liberal supply of carbohydrates is essential for foetal
energy production, since the foetus derives energy
almost entirely from this source. All the supply of
glucose to the foetus is obtained by the passage
across the placenta. Some lipids essential for growth
and development are transferred across the placenta
in early weeks of pregnancy while others are
synthesized by the foetus in the latter weeks. Protein
transfer ism for the most part, achieved by the
breakdown to amina acids o the maternal side of the
placenta followed by the active transport.
Essentials concerned with maintenance of bio-
chemical homeostasis like water, electrolytes,
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oxygen and CO2 are transferred by simple diffusion
taking only a few minutes while other nutrient
materials transferred by active transport take only 30
minutes or so.
The rate of growth of a cell depends upon the
availability of nutrients. In the foetus this depends
upon the maternal blood arriving at the placenta and
the transfer of the nutrients across the placental
membranes to the foetus. The concentration of
nutrients in the maternal blood is the same except in
extreme condition of starvation. Even here nature
sees that important centres of the foetus like brain,
liver and heart are well supplied with nutrients and
are thus well protected.
Yet pregnancy can be trying and requires a lot of
forbearance on the part of ther mother.
Though from a biologic point of view
pregnancy and labour represent the highest
function of female reproductive system and a
priori should be considered normal; yet the
manifold changes in the maternal organism
during pregnancy described above however
render the borderline between health and
disease less distinct and slight derangement of
but little consequences in ordinary
circumstances may presage pathologic
conditions that seriously threaten the life of
mother or child or both.
While everyone else at home is happy to
observe early morning sickness (occurs in 50% of
cases) as a symptom of conception, yet for the
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patient it causes so much of unpleasantness and
discomfort. She is at her wits end unable to take
anything, even the smell of food becomes
unbearable, the patient becomes weak and
exhausted. If neglected the condition many drift
unnoticed into a condition of hyperemesis with all its
dangers to life.
As the pregnant woman recovers from this
symptom and the pregnancy advances she feels well
and is in good frame of mind and spirit, she observes
gradual distention of the abdomen by the enlarging
uterus and develops pigmentation on the abdomen,
breasts which also become heavy and occasionally
pigmentation on the face. Her skin becomes
thickened and the features becomes coarse.
There is a great diminution of the bowel
peristalsis probably due to smooth muscle hypotonia
which becomes more pronounced in pregnancy and
constipation can be troublesome in some patients.
Iron supplements may make constipation worse.
Haemorrhoids occasionally first appear during
pregnancy and bleeding may result in loss of
sufficient blood as to cause iron deficiency anemia.
Oedema of feet and legs may occur as a result
of increased venous pressure and the pressure of
the pregnant uterus on the pelvic veins. Oedema
alongwith proteinuria and rise of blood pressure
constitute the triad of symptoms/signs of pregnancy-
induced-hypertension occurring in 5 to 7% of cases.
Pregnancy predisposes to varicose veins in the
lower extremities and symptoms may vary from
cosmetic blemishes with mild discomfort at the end
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of the day to severe discomfort or occurrence of
superficial thrombophlebitis.
Physiological changes in the urinary tract during
pregnancy predispose to acute pyelonephritis
leading to urinary tract infection.
During the latter months of pregnancy cramps
in the calf, abdominal wall, back and elsewhere are
not uncommon. Relaxation of the cardiac sphincter
and reflex of gastric contents into lower oesophagus
referred to as Heart-burn of pregnancy is often a
distressing symptom. Palpitations, insomnia fatigue,
dizziness and faintness are occasional symptoms.
As a result of marked softening of the ligaments
and an increase in the synovial fluid, there is a
considerable mobility in the sacrococygeal, public
and sacro-iliac joints. In some cases the relaxation
may be so great that the patient experiences
incapacity, pain in the joints and finds it difficult if not
impossible to walk. The relaxation of the pelvic joints
also causes a degree of pelvic instability, so that the
woman in late pregnancy adopts a characteristic
waddling gait. The increased protruberance of the
uterus causes a progressive shift of centre of gravity
anteriorly; so as to prevent herself from falling
forwards; pregnant woman throws her shoulders
backwards, straightens her back and neck and there
is of necessity a compensatory increase in lumbar
lardosis causing severe backache. All this is
designated as Pride of pregnancy. The pregnant
woman deserves all the respect and consideration
that she demands. But unfortunately it is very much
lacking today.
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Scriptures say that women have to play a many
faceted role in life that of a lover, wife, mother,
friend, advisor and as sahadharmacharini (in respect
to the husband). Here it is the acceptance of the
motherhood which is essential and necessary for
safe pregnancy. Women should have a positive
attitude towards pregnancy and the anticipated child.
The pregnancy has been planned and was happily
accepted when its existence became certain. She
should have a manifestation of pride in self identity
as a mother or mother to be. Any denial of this may
psychologically lead to various problems
enumerated above like vomiting, pregnancy-
induced-hypertension and repeated abortions etc.
Equally important are the qualities of to bear
and to forbear which are the watch words. Mother
nature does everything for the safety of the mother
and foetus. Yet a determination to remain healthy
and normal with a minimising of discomforts and
acceptance of anatomic and physiological changes
with minimal physical disabilities is an essential
prerequisite on the part of the mother. One should
not feel helpless and leave everything to God that
He should only look after and protect. (it is just like
leaving alighted candle outside in the open and pray
to the Lord to see that the flame is not put off).
All the above disconforts the pregnant woman
forbears and by judicious and timely advice
regarding details of personal hygiene, the medical
attendant can do much to obviate such disturbances
and to prevent them from developing and
constituting a serious menace to health. The
expectant mother is usually well and in a respective
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frame of mind and will follow all the health measures
advocated which are of benefit for her child and for
herself.
Til til jeevan dekar til til badhana
Mother gives up her nutrition and strength like a
til oilseed to make her foetus grow in the womb.
THE FOETUS CAN LISTEN AND REACT
FROM MOTHERS WOMB
It is said in the Bhagvatam that Rani
Leelavati wife of King Hiranyakasapu was pregnant
Sage Narada taught her the Narayana Mantram.
Prahalada in the womb listened to this Mantra and
soon after birth started saying Hari (Narayana) of
course much to the annoyance to his father.
In the Mahabharata Arjuna was one day
teaching his wife Subhadra about Padmavyuham
(chakravyuham) (a strategy of war). But he could not
complete it as Lord Krishna came and taunted
Arjuna for telling a pregnant lady about war
strategies. Abhimanyu, who was in the womb,
listened to all that was told to his mother by the
father to the extent of how to enter into
Padmavyuham and fight but not how to come out.
Later in his life he ad no chance to learn from his
father the complete strategy. During the
Mahabharata war when Dronacharya planned
Padmavyuham Krishna and Arjuna were not there
and when challenged, Abhimanyu came forward to
fight in spite of protestations from everyone including
his mother Subhadra. Abhimanyu said that when the
enemy had come and challenged for fight, not go is
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a disgrace or Apakirti worse than death and took his
mothers permission. He died fighting, not to go is a
disgrace or Apakirti worse than death and took his
mothers permission. He died fighting, not knowing
how to come out of it. Abhimanyu got
veeraswargam (Heaven meant for noble warriors)
and is remembered even today for his valiant death.
When Kahoda was reciting Vedas, the child in
his wifes womb who was listening to the same could
not bear the wrong pronunciation and told his father
that there were eight mistakes. The father not
realising that the child in the womb could speak,
mistook his wife for the same. He got angry and
cursed his wife that the child would be born with
eightfold contorted body. That was how
Ashtavakra was born.
The above three examples indicate that the
foetus can and does hear when in the womb, can
remember the same after birth and the behaviour
and actions depend upon what it is exposed to listen
while in the womb. The three gunas Satvic, Rajasic
and Tamasic qualities after birth may also depend
upon what it is subjected to hear in the antenatal
period. If the mother reads religious books, hears
songs of bhakti and devotion during pregnancy, the
child after birth and later in life will also be inclined to
hear the same and his behaviour and character will
be in the same way. In a family where there are
fights and quarrels and baby in the womb listens to
these the child may imbibe he same.
Even the latest research confirms this view. It
is observed that certain behaviours of the infants in
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response to environmental change has been called
Orienting Response. As a new stimulus is received
in the auditory and or visual or other sensory field,
the infant becomes more alert, with suppression of
spontaneous movement, with a likely turning of the
head towards the stimulus and with physiological
changes in heart rate. There is a tendency for the
heart rate to decelerate when the baby orients to a
more or less familiar stimulus, whereas acceleration
occurs when a totally unfamiliar and noxious
stimulus is received. When a substantially
unchanging new stimulus becomes repetitive, the
orienting response rapidly habituates; there is less
startle reaction or cardiac acceleration and as the
stimulus becomes familiar, cardiac deceleration may
supervene. (Nelsons Paediatrics). Foetal electro-
cardiographic studies show, where foetus is
stimulated (Accoustic Stimulation test), there is
tachycardia. This test is done to distinguish whether
a baby is anoxic or at rest (sleep).
Bonding : It is the social milieu of the parents, the
mothers experiences during pregnancy
(representing hopes and fears of the parents) and
events surrounding labour and delivery all these
experiences have the effect of bonding the parents
to the child after the child is born. Bonding consists
of those emotional ties that characterize the
relationship between each parent (or other
participants in this social event) and the infant who
becomes a central figure. During the next few hours,
days, weeks and months the infant reciprocates this
bonding with his or her attachment to the significant
persons in the environment to whom he or she will
turn to in future for protection, nurturance and
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love. (Nelsons Paediatrics).
All parents want their children to become
cultured, obedient, intelligent and patriotic citizens
when they grow up. The ideal time to inculcate in a
child is during the prenatal period. Prenatal
Thought Radiation Experiments (Conducted at
Hospital For Peace of Mind Lonavala) have given
positive results. Seventh month of the pregnancy is
chosen as suitable as by this time all growth
parameters are completed and the response of the
foetus o thought process is better. The main feature
of the experiment is transmission of thought waves
on a particular plane by the researcher.
Concentration of the parents and a state of
equilibrium is brought about and the foetus is
suggested to a prayer. Also when the foetus is
informed about the colour the mother is
concentrating upon foetal pulse rate may show
variations depending upon his/her likes and dislikes.
This can be detected at a very early foetal stage of
development and his/her good qualities reinforced.
Even psychologists now a days judge the nature of a
person on the colour he chooses and remedial
measures are suggested based on the colour.
Similar programme is also conducted by the
National Institute for Habitat Management,
Bhubaneshwar where pregnant women are trained
to teach their offspring a whole lot of things while
they are in he womb. The training here is however
offered between the fourth and fifth month as the
infants brain would develop in the second trimester.
During the process which is called psychosomatic
reaction between mother and child through blood
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circulation, the brain of the offspring would become
powerful to receive signals through the mother.
All this is based on the hypothesis that the
Foetus can be positively influenced in utero. A study
in 40 cases has shown that physical condition,
milestones in development and qualities of courage
and peace (obedience, good memory,
understanding, cooperation, satisfaction and love)
observed in 60% while qualities of fear and rage
occurred in 30% of the children followed for seven
years after the birth. These tests seem to be of great
value in building a cultured, courageous and tension
free future generation.
What our scriptures say regarding the influence
on the foetus and child.
Prakriti is the muladhaara (source) for Shakti.
One must do puja to Prakriti and through it get the
blessings of the Lord. The first depends upon mans
earnest desire and trial and the second one is the
grace of the Divine. Prakriti and Paramatma are like
negative and positive currents. Even if the
Paramatma is the positive and all powerful. Yet
without the negative Prakriti there is no Shrushti
(creation) of the world. For this Shrushti, Prakriti is
the muladhara. Even if one has good seeds, unless
one puts in the earth one does get any results.
In the same way womb is likened to Prakriti or
Bhumata. If the beeja or seed which is put in is good,
then good healthy children are born. If one puts
neem seeds in the earth, how can be expect to get a
mango grove. Any good seed or beeja always come
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from the type of nutrition we take naturally whether it
is Satvic, Rajasic or Taasic. It the mother indulges in
smoking or excessive drinking this is reflected in the
growth of the child. Growth retardation was reported
in smokers and in cases of foetal alchohol
syndrome.
Secondly, even if the seed is good if the bhumi
or earth is not good, the produce will not be good. It
is our elders advice that all the weeds should be
removed from the earth before sowing the seeds.
Thus environment is equally important. Similarly,
good, nourishing environment in the uterus is
essential for the proper development of the foetus.
Thirdly, the thoughts prevalent in the mother
throughout pregnancy have also a positive effect on
the type of baby born. Even the teachings and
training of the children and the samskaras given by
the mother in childhood also play a great role in the
personality of the children. In short, Mother is the
first Guru for anyone in life. Rama became God and
attained name and fame because he was born to
and brought up by Kaushalya. Lava and Kusha were
similarly brought up by Sitamahasadhvi and hence
hey attained greatness. Chhatrapati Shivaji attained
greatness because of the teachings and bringing up
by Jijabai. Gandhi became Mahatma because of his
mother Putlibai. At all times and at all moments
because of the protection of the Mother, mankind is
spreading its perfume. The hand that rocks the
cradle is the hand that rules the world. (WR
Wallace).
The final development of the child, as he grows
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in age also depends on the prevailing environment
which it faces. To cite an example the father of
Ravikiran, the child prodigy of Carnatic music
wanted that his son should develop into a musical
genius and so right from birth he saw that the child
was exposed continuously to a musical environment.
The result is that even at the tender age of three
years Ravikiran was able to identify all the ragas in
Carnatic music and later developed in a musical
prodigy.
In a similar analogy Bhagwan in his divine
message in Bhagwad Geeta (Chapter 13) says that
our (human) body is Prakriti or kshetra and the Lord
in us (Paramatman) is the Purusha or Kshetragnya.
In mans endeavour to realise Bhagwan he must see
that all the vasanas (attachment to sense objects)
should be removed first. Then only the Kshetra will
become pure with good thoughts words and deeds
and only thereafter can one aspire for Moksham
(Bhagwan Sri Satya Sai Babas Divine message).
ANAEMIA IN PREGNANCY
(Mother Helps in Development of Foetus
At the Expense of Her Own Health)
In our country anaemia in pregnancy is a major
public health problem. It is one of the commonest
causes of high maternal mortality rate. Anaemia is
directly responsible for 20% of all maternal deaths
and in about 20% it is a pre-disposing factor.
If the haemoglobin level is below 11 gms%
during pregnancy, it is indicative of anaemia (SHO).
If the level falls below 8.5 gms% it is moderately
sever and various complications occur. Below 5
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gm% of haemoglobin, the anaemia becomes very
severe and especially during their trimester of
pregnancy cardiac failure occurs and the patient
requires hospitalization. Statistics have shown that
moderate anaemia in pregnancy occurs in 40-70% in
different parts of our country. Moderately severe
anaemia (Hb<8.5gm%) is seen in 10% of cases and
the incidence increases with parity. (Post Graduate
Obstetrics & Gynaecology IV Edtn).
Physiological anaemia of pregnancy: There
is an increase in maternal blood volume by 50%
during pregnancy. Both the plasma and erythrocytes
increase yet as there is a disproportional increase in
plasma volume (35%) compared to the increase in
red cell volume and haemoglobin mass (13%). There
is a positive haemodilution. This leads to a decrease
in haemoglobin and haematocrit levels and has led
to the term physiological anaemia of pregnancy.
This physiological anaemia can be prevented and
the haemoglobin level can be kept above 11gms%
with iron supplements. However if the haemoglobin
but definitely pathological.
Nutritional deficiency is the main cause of
anaemia in our country. Of this, iron deficiency alone
is by far the commonest. There is associated folic
acid deficiency in 30-40% of cases.
Iron deficiency anaemia: Iron content in an
average Indian diet is 20-22 mg., but the diet is
deficient in vitamin C, calcium and proteins which
are essential for iron absorption. Also the diet
contains phytates which inhibit iron absorption. At
least 10% of dietary iron should be absorbed to
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maintain iron balance. But only 3-5% of dietary iron
is absorbed as shown by radioactive studies. To
maintain iron balance in pregnancy a minimum of 4-
6 mg. should be absorbed. If the dietary iron
contains 40-60 mg. of iron then only the desired level
of iron can be met with. Even the best of diets do not
contain this amount of iron.
Most women in our country enter pregnancy
with little or no iron reserve. They are poor and
malnourished; they suffer from worm infestation
especially that of hook worm which leads to iron
loss. They lose blood due to haemorrhoids. Iron is
lost every month to the extent of 15-30 mg during
menstruation and many women suffer from
menorrhagia i.e. excessive bleeding during periods.
They have repeated and closely spaced pregnancies
and also bleed after delivery (post partum
haemorrhage) which again deplete iron store with
each successive pregnancy.
All this is reflected in higher incidence of
anaemia in high parity group.
Iron absorption and utilization is also hampered
by infections of urinary and gastro-intestinal tracts
which also adds to the increased demand of iron
during pregnancy thus aggravating iron deficiency.
The baby in the latter months of pregnancy
makes a heavy demand on maternal iron and the
average foetal requirement is about 375 mg.
Folic acid deficiency: This causes
megaloblastic anaemia of pregnancy which occurs in
10-20% of cases. In the diet folic acid is present in
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green leafy vegetables, pulses, liver and meat. As
such Indian diet is a poor source of folic acid and our
cooking methods tend to destroy folic acid to a
considerable extent. In women who have
haemoglobin level less than 8.5gms% there is not
only iron deficiency but also in 60% of these the
bone marrow has a megaloblastic reaction and such
anaemias are called as dimorphic anaemias. Vitamin
B12 is present in all animal foods and in countries
where animal food is scarce vitamin B12 deficiency
occurs.
Effects of Anaemia on Pregnancy
The symptoms are often not pronounced in mild
and moderate forms. Progressive deterioration of
haematological status occurs with each succeeding
pregnancy. Symptoms when present in severe cases
consist of fatigue, dyspnoea, palpitation, loss of
appetite and digestive upsets. The patient typically
presents a picture of pallar of all mucous
membrances-eyelids, tongue, lips and the nails show
cholinechia (spoon shaped) and there will be marked
oedema of the lower extremities and occasionally
the rest of the body as well.
Folate deficiency in the early weeks of
pregnancy has been associated with abortion and
congenital malformations of the foetus, especially
neural tube defects. Other complications like
accidental haemorrhage, toxaemia of pregnancy,
increased incidence of urinary tract infection,
prematurity, still births and neonatal deaths also
occur in cases of megaloblastic anaemia of
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pregnancy. Severe forms of anaemia in the third
trimester are invariably associated with cardiac
failure.
Labour in severe forms of anaemia can be
premature and precipitate but not in mild and
moderate cases; but accidents of labour especially
those involving haemorrhage and shock, are
rendered correspondingly more serious. After
complications like Antepartum haemorrhage
(abruption placenta or placenta praevia), even a little
loss of blood in the post partum period will tip the
scales towards a state of collapse. Patients who
come into labour with haemoglobin level of 8.6gms%
or less are at serious risk in this respect. Those with
haemoglobin 5 gms% or less have an already over
functioning heart develop severe decompensation
(acute heart failure) either during the 2
nd
state or
immediately after labour. A woman approaching
labour with a haemoglobin of 65% (9.6 gms%) or
less faces it with some perils and all ante natal
conditions producing fatigue exaggerate the effects
of labour itself. Her ability to cope up with infection in
the puerperium is much undermined by anaemia and
they are also prone to have a high incidence of
thrombophlebitis and thromboembolic phenomenon.
Her recovery in the post natal period will be greatly
retarded to such an extent that she may now face
years of chronic sub health.
Effects on the foetus: In mild and moderate
cases the foetus is born with full compliment of
haemoglobin. The foetus takes every thing from the
mother irrespective of her haemoglobin level in
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short it is like a parasite. But in very severe cases
and in those of low income groups it was observed
that the foetal stores of iron, folate and B12 is only
50-60% of the affluent population. Their birth weights
are low as a result of prematurity or some of them
are actually small for date. Since breast milk in these
people may not provide all nutrients, they run the risk
of developing anaemia very early in infancy as well
as infections.
Prophylaxis: While appropriate treatment is
given and individualised in each case depending
upon the type and severity of anaemia and the
period of gestation and also the presenting
symptoms the most important aspect is that of
prevention. Study group in nutritional anaemia
recommended 60 mg of elemental iron with 500
micrograms of folic acid should be given as
supplement in the last 12-16 weeks of pregnancy for
all cases. At this level of iron the side effects are
minimal with less chances of gastro intestinal
irritability and intolerance when given on empty
stomach. There is a false belief that iron should be
taken after meals but it is observed that absorption is
reduced by 1-4% after a full stomach. With the
supplement, levels of haemoglobin are not only
maintained but also bring about an increase above
pre-supplement levels in about 90% of women.
However in 8-10% of cases the haemoglobin levels
are still low in spite of therapy and this cannot be
explained. As low as 5 mgs of vitamin B12 are
recommended to maintain pregnancy requirements.
All this of course in addition to the prescribed dietary
regulations suggested in normal pregnancy as well
as repeated haemoglobin estimation for the early
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diagnosis of anaemia.
Anaemia may antedate conception, it is often
aggravated by pregnancy and accidents of labour
may precipitate it. It is one of the prime concerns of
ante natal care to forestall it for the safety of labour
may precipitate it. It is one of the prime concerns of
ante natal care to forestall it for the safety of labour
and puerperal state, let alone the future health which
in a large measure depend upon the state of
patients health.
As I write about the subject of anaemia in
pregnancy my thoughts go back to all the cases
seen and treated during all these years. Most of
these patients belonged to the low socio-economic
group, never attended ante natal clinics usually
multiparrae with rapid succession of pregnancies
without spacing and also had some other obstetric
problem. Some had twin pregnancy, others admitted
for antepartum bleeding. In many of them
haemoglobin was less than 5 gms% and in a few it
was just 2-3 gms%. They were admitted with
dyspnoea, breathlessness tand palpitation. Some
had gastro-intestinal upset like diarrhoea and others
with severe oedema and had severe hypoprotinemia
in addition. They looked very pale and were
cyanosed and on examination presented incipient
signs of heart failure due to dilated heart. Some
could not stand labour and developed acute heart
failure and died during the end of second stage or
mostly after delivery of the placenta or thereafter due
to collapse or obstetric shock.
Some of the patients belonged to the working
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class yet the husband used to drink, gamble, beat
the wife and take away all what she used to earn.
Even when told that the patient required blood for
transfusion etc, the husband and relatives not only
refused to donate blood but used to run away from
the hospital leaving the patient to the hospital care
and never bothered about her welfare afterwards.
While the above state of affairs are still
prevalent in rural areas and in uneducated people
yet a much similar situation though not to the same
extent, is observed today in semiurban or even
urban population like people living in slums. The
mother of the house is the most neglected of the
whole lot. She has to care for the needs of the
husband, children, in-laws and whether the lady is
pregnant or other wise, she does not get proper
nutrition. Many of the mothers have never fully
regained a good blood picture and anaemia may
follow from one pregnancy to the next without
respite. They tend to feed their children at the
expense of their own nutrition so that they are
consequently very short of vitamins and first class
proteins. They are too busy to attend to their own
health and in a rapid succession of pregnancies and
periods of lactation are likely to become seriously
depleted of their calcium. No wonder they suffer from
dental caries, bone and joint pains and from
oesteomalacia in severe forms of calcium deficiency.
So many posters are put in the ante natal clinics
(and also advertised in the TV) as to what is the
ideal diet for pregnant patient including proteins,
cereals, leafy vegetables and how much of milk they
have to take daily. Even low cost diets giving same
calories and proteins etc are also suggested. Yet
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one wonders how many people are able to afford the
same since the cost of living is going up everyday.
Even middle class people with fixed incomes cannot
afford to buy enough milk, let alone other food
supplements. What is surprising is the number of
cases of anaemia observed in patients belonging to
the affluent families. Probably eating fast foods has
become the fashion of the day and their diets are not
nutritious. It has become routine practice to give or
prescribe all ante antal patients iron and folic acid
tablets. Yet many patients cannot afford to buy and
in others even if they could buy or the tablets are
given in hospitals the patients do not take them
regularly as occasionally the tablets cause diarrhoea
or constipation. Non compliance of taking the
medicine or haphazard way of taking is a very
common feature in our present day set up. This
applies to all people pregnant or other wise.
In any household, rich poor or middle class, the
most important person is the mother. She is the
centre or hub round which all the activities take
place. Her health care is of utmost importance all
the more so during pregnancy. Pregnant mother is
the custodian of the future health of the nation. If she
is anaemic, the offspring will also be anaemic though
not at birth but definitely later. They will not keep
good health and are prone to infections. During the
entire period of pregnancy and childbirth and later in
bringing up of children the mother sacrifices
everything of hers for the welfare of the family.
Mothers have even sold their jewellery for the
education of their children and all this they did in the
spirit of duty and not expecting any return as said in
Bhagawad Geeta (Chapter 2):
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Karmanye va adikaraste; ma phaleshu
kadachana.
Mothers sacrifice is likened to the sacrifice of
the Lord. Whenever He is born, it is for the welfare of
humanity (Lokakalyanam). Take the life of everyone
of the avataras. Lord Rama sacrificed to uphold the
order given by his faterh, Lord Krishnas life is one of
tyaga from the time he was born in the jail, had to be
brought up by foster parents, always being
threatened by the wily Rakshasas and even in the
end he serves as a Sarathi for Arjuna. The Lord
himself has no qualms about doing service to
humanity. Bhagwan Gautam Buddha relinquished
the entire kingdom in search of truth. Even so, Lord
Jesus life is full of sacrifice, mercy and compassion
from the beginning. (Bhagwan Shri Satya Sai Baba).
It is a sorry state to see that many mothers are
being neglected by children when they grow up. Not
only mothers are not being looked after, they are
made to work and kept with them as long as they are
found useful. In short, there is no retirement for
mothers in life. It is a pity to observe children who
grew up from poor or middle class families and
achieve high position later in life sometimes feel
below their dignity to introduce their parents to
others. Some even go to the extent of sending their
parents to Vriddhashrama (home for the aged)! It is
sad the grand children are deprived of the company,
affection and love of grandmothers (parents). The
impact of the stories which often point out to moral
values heard from the grandparents cannot be
replaced or substituted by any story books. I only
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pray for the day when the homes for the aged are
scrapped and the old parents are looked after by
their children.
ABORTION PROBLEM
(LOVES LABOUR LOST
Abortion is termination of pregnancy before the
period of viability. Incidence of spontaneous abortion
is considered 10 to 15% of all pregnancies. The
aetiological factors are divided into two main causes.
1. Defective germ cells.
2. Faulty maternal environment.
In a high proportion of cases which abort the
abnormal foetal development may manifest itself as
a blighted ovum which describes an empty sac in
which the embryo has not developed beyond a small
clump of cells or there may be a clearly recognizable
foetal abnormality. The abnormal development of the
embryo or the foetus may be due to a structural
abnormality or chromosomal abnormality. It is also
possible that genetic defects leading to the
absence of a specific enzyme could cause abortion.
Chromosomal abnormalities account for a large
proportion of aborted concepts in about 50% of
cases. Commonest is autosomal- trisomy affecting
16,22,21 and 15 chromosomes. Monosomy X
chromosome accounts for 1/5
th
of all abnormal
karyotypes. Triplody and tetraprody are also seen
with reasonable frequency. Structural abnormalities
like neural tube defects may be present in other
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cases.
The other important cause of spontaneous
abortion is faulty maternal environment. It may be
that the corpus luteum and the developing placenta
do no produce enough progesterone and oestrogen
for proper nidation and the decidua is poorly
developed not giving enough nutrition for the
developing embryo. There is a correlation between
maternal diet and foetal development. Vitamin C, P
and Folic acid are essential for nucleic acid
production and deficiency of these can cause
defects in the developing embryo.
Anatomical uterine defects like double uterus,
septate uterus or bicornuate uterus in all these the
fertilized ovum may not only not get proper nutrition
but the growth is also affected by the abnormality.
Even if the pregnancy continues for some time all
these also have an incompetent cervix and
pregnancy gets terminated later in second trimester.
Implantation over a submucus myoma or over a scar
again leads to nutritional deficiency and failure of
growth. Hypertension in pregnancy causes changes
in the decidual vessels and results in less blood
supply ad nutrition.
In both the above two causes of abortion, most
often the embryo or ovum dies first and the abortion
is only the end process. Mother nature does not
want defective children with various abnormalities to
be borne and live in the world. Abortion in such
cases is a protective phenomenon on the part of
nature to get rid of such foetuses. However it is not
known why some chromosomal anomalies like
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Trisomy 21 (Downs Syndrome) or Mongolism of
Monogamy X (Turners syndrome) lead to abortion
in some cases and proceed to term in others. It may
be that those who abort have some other
abnormality in addition to chromosomal defects
which precipitate abortion. How one wishes that this
should happen in all cases! Probably those who go
to term and deliver have still some Karma left to be
done in this world. But one also feels sad not only for
them but lifelong misery for the parents. May be they
have done something in the past life to get such
children in this present life. This is what is called
Runanubandha (a bondage between the parent and
the child) and the parents have to pay off this debt to
the child in this present birth by serving and looking
after it.
Although early pregnancy loss is often
considered to be less important than the loss of baby
in later pregnancy this attitude is inappropriate.
The loss of wanted baby is always distressing to the
mother irrespective of timing and this probably is
more true in recurrent abortion. In spite of
assurances many young mothers feel that there is
something wrong with them and feel let down
Loves Labour is Lost.
The second cause of faulty maternal
environment as a cause of abortion only stresses the
place of a good environment in the healthy growth of
an individual. Even if the child is good and intelligent
if he/she is brought up in unhealthy environment
they shall not come up in life in the right direction as
is seen in children born in an atmosphere lacking in
peace and morality. Their manners and attitudes are
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different. The children do not study nor do they
attend the school regularly, fail in the examinations
and latter on drop out from the school. They develop
bad habits and be in the company of bad people. If
the social structure is changed and all these children
are brought up in a healthy atmosphere given
proper nutrition, guidance and training in right
direction and be in the company of studious, well
mannered and good students, all these people will
also come up well in life. It is observed such children
thus brought up are equally intelligent and do well in
their examination as well as career. They play
written by Bernard Shaw (Pygmalion) only shows
how a lady on the streets can be changed and
transformed in such a way that she is taken as a
princess by everyone. For upward evolvement in life
our ancient scriptures stress on right company
right Satsanga (The company of good-minded
persons).
Habitual Abortion & Repeated Reproductive
Failure
(Can be Trying on the Part of the Mother and
Requires Patience and Perseverance).
Habitual abortion refers to three or more
consecutive abortions. In addition to the factors
enumerated in the aetiology of abortion there are
other factors like maternal syphilis, infections like
toxoplasmosis, incompatible blood group like ABO
and RH incompatibility, hypertensive conditions like
pregnancy induced hypertension, nephritis, essential
hypertension and incompetent cervix. In other
pregnancy may go beyond 28 weeks of gestation
and the patient either has premature delivery or
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intrauterine death of the foetus.
While in some of these cases the cause can be
determined, in many the cause can be multi-factorial
and is not known. Unexplained recurrent abortion or
reproductive failure is a term covering an
assortment of mechanisms, varying with current
knowledge and intensity of investigations but still
amounting to around 50% of repeated foetal loss. In
such cases the cause can be immunological.
While the mechanism leading to the mother
accepting the foetus for continuation of pregnancy is
not fully understood it has been suggested that a
failure of a normal immune response could be an
important factor in the aetiology of repeated
abortions. Such a phenomenon is not confirmed in
all the cases.
Cases of repeated abortion are treated with
complete bed rest sometimes extending throughout
whole course of pregnancy, and with hormone
treastemtn with chrionic gonadotrophic
hormone/progesterone; Isoxysuprine tablets given to
prevent contractions; folic acid and B complex with
vitamin C prescribed from even before the start of
pregnancy and continued for 3 months or more and
in additional good nutritional supplements are given.
Cervical circlage done after confirming there is no
abnormal foetus by ultrasound in the second
trimester of the pregnancy; antibiotics are given to
treat infections like syphilis, toxoplasmosis and for
bacteruria of pregnancy and urinary tract infection.
In the later weeks of gestation careful foetal
surveillance is done by routine examination whether
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the uterine size corresponds to the gestational age;
regular check up done for detecting early raise of
blood pressure and if so, treated; Blood sugar as
well as urine examinations are done to rule out
diabetes. Volume of liquor and whether there is
intrauterine growth retardation observed by
sonography and later followed by non-stress test etc.
for the well being of the foetus.
It is sad to see these patients who become
more and more apprehensive with each foetal loss
and the obstetrician is at his wits end in the
management of these cases. Yet with the
determination and will power and perseverance and
willingness to accept the stresses of pregnancy the
patients are often rewarded with a live child. A
report covering 195 couples with recurrent abortion
emphasizes how extraordinary good results would
have to be to carry conviction. In 37 couples with 3
consecutive, spontaneous unexplained abortion 32
(86%) had a successful pregnancy with Tender
Loving Care alone. There is no evidence that a
patient who have habitual abortions; when she finally
carries pregnancy to term delivers an abnormal
child.
The saddest part of all these is while the mother
patiently undergoes all the stresses throughout
pregnancy and finally gives birth to a live child after
either vaginal delivery or after caesarean section, the
relatives including the husband and the in-laws etc.
asks the first question How is the child? They are
only happy to know about its well being. Many a
time they are even depressed when the baby is a
female. Yet nobody bothers or cares for mothers
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health. It is not sad! Is the mother made to only
undergo all the torture!
In my own professional experience I have had
occasions to treat patients who had abortions
varying upto 6 to 10 times, some in the first trimester
and some in the second trimester. In most of them
the cause was unexplained. I used to keep them at
complete bed rest in the hospital for periods varying
from 5 months to 10 months. In a few I kept them in
the hospital for quite some time after the delivery. I
had learnt one thing; i.e. one should not leave hope
in these unfortunate cases. With a little cooperation
and willingness on the part of the patient to take bed
rest (of course the only time real bed rest women get
is in the hospital) and with sympathy, assurance, etc.
one can take these patients to term so that they can
be blessed with a live healthy baby.
I am reminded of the story of Robert Bruce who
saw a spider climbing a wall, which could not do so
for 6 times and in the seventh time succeeded.
Taking this clue he himself succeeded in his
endeavour which he could not do for many a time. In
the same way the obstetrician as well as the patient
should not leave any stone unturned and strive for
successful continuation of pregnancy and labour.
Views regarding occurrence of abortion :
Role of consanguinity in the causation of congenital
abnormalities, abortions and stillbirths is ambiguous.
Scientific research showed that co-sanguinity or
kinship increases the likelihood hat a couple will
share autosomal recessive gene. First cousins share
1/8 of their genes and second cousins share 1/16.
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Even if there is no family history of autosomal
recessive disorder, yet the couple can be carriers of
deleterious gene and here is an increased risk for
genetic disorders, miscarriages, and stillbirths in the
offspring of first cousin marriages. But the risk is
relatively low. Matings of individuals more closely
related than first cousins, involves significant risk of
congenital anomalies and naturally this practice is
proscribed by law. Several investigations have
established the risk for anomalous children to
brother and sister or parent and child matings to be
as high as fifty percent. (Williams Obstetrics 1993).
While this is so, in practice one does not observe the
same in all consanguineous marriages. Marriages
among first cousins or marrying maternal uncle is
still prevalent in certain communities and all the
offspring not only were normal but have high
intelligence and academic brilliance. Anomalies were
observed only if the co-sanguine marriages are
repeated in the next generation.
It is a common observation that children born
our of marriages between different races or
nationalities are usually very brilliant. This factor
seems to be the basis for research in agriculture and
animal breeding producing more productive seeds
and better animal progeny. One cannot explain
why ? It is the genetic disparity which is responsible?
Surprisingly in such marriages the incidence of PIH
(Pregnancy Induced Hypertension) is more, which is
not observed in consanguineous marriages.
Even now Sagotra marriages are not
advocated. Unfortunately many marriage proposals
are discarded on this ground. But clinical experience
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and research does not support it.
Another unconfirmed but strongly held belief is
the marriage between people belonging to two
difference castes. In anuloma where the husband
belongs to a high class or strata and the wife of
lower strata the offspring will be good while it is
reverse in pratiloma when the wife belongs to a
higher caste and husband to a lower caste but in
practise one sees that a Pandita-putra (son of a
great scholar) need not always be brilliant and in fact
most of them are the other way around. The oft
quoted example of anuloma is that of Vidura in the
Mahabharata who was born to Vedavyasa and a
maid, was a great scholar who was the Prime
Minister and administered the country on principles
of dharma (Vidura Niti) which even today have
relevance.
Indeed there are many phenomena which
cannot be explained! To give an instance the
occurrence of twinning in cases where the ovum is
starved; ie deprivation of nutrition and or oxygen to
the developing fertilized ovum, if not lethal by itself
may result in the production of twins or abnormal
births depending upon the timing of such deprivation
(Stockard Williams Obstetrics Ed Eastman). It is
not strange! Starvation is a stimulating factor which
our elders prescribed and preached for a spiritual
progress of man.
Except in a very few rare cases, the chances of
a child developing congenital abnormalities,
pregnancies ending in miscarriage or stillbirth or
children after birth being normal, brilliant or
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otherwise depend upon many factors most
important of which is the praarabdha (effect of ones
Karma in past life, but the One which overrides
everything else is the Kripa or the blessing of the
Lord Almighty). All other factors are unpredictable.
Bhagwan Lord Krishna (Stanza 14 Chapter 18) in
Bhagwad Geeta said that there are five essentials
for the successful accomplishment of all actions.
The seat of action Adhishthanam or the seat;
(ie the physical body).
Karta or agent (i.e. personality or the empirical
ego).
Karanam or instruments or organs the 10
indriyas or sense organs, manas, buddhi and
ahamkaara.
Chesta efforts and functions of Prana or vital
energies or breaths in the body.
Lastly even if all these are present the fifth one,
i.e. Daivam or Providence or Bhagwans will at
work is essential as He is the regulator of all work.
So in the ultimate analysis one will be successful
in any work only with the blessings of the Lord
Almighty.
The valuable contributions of the Late Dr VN
Shirodkar in respect of treatment of cervical
incompetence, ( a very important cause of mid-
trimester abortion) need special mention. He was the
first to suggest cervical circulage in the management
of these patients which has resulted in several
patients going to term. Even today, in many East
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European countries, whatever the procedure done, it
is designated as Shirodkars stich as a tribute to his
contribution. Why should not we in our own country
honour him similarly?
ONSET OF LABOUR : STILL AN ENIGMA
When the child is grown fully and the mother
cannot continue to provide him with enough
nourishment, he becomes agitated, breaks through
the membranes and incontinently passes into the
external world
Hippocrates
I is truly one of the mysteries of nature that life
starts as a single fertilized cell which develops into a
fully grown baby nourished all through in the
uterine cavity till full duration of gestation. The
uterus suddenly becomes active and within a short
span of time expels the foetus. This is true for all
species whether the foetus weighs a few grams of a
21 day pregnancy in a mouse or whether it weighs
several hundred pounds at the end of 640 days
pregnancy as in the elephant labour begins at a
specific time. The factors regulating this highly
synchronized sequence of events are obscure.
Labour can neither be initiated nor stopped at will.
The old adage When the fruit is ripe, it will fall,
symbolizes the extent of our knowledge of labour.
The fundamental question is not what initiates
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uterine contractility (as they are there already) but
how these painless random contractions are
converted into exquisitely coordinated efficient
contractions that dilate the cervix and expedite
expulsion of the child. Of the main theories regarding
the onset of labour none alone affords an exact
explanation but each, in all probability, plays a role.
Uterine Stretch Theory: This is the oldest theory and
is based on the presumption that any hollow viscous
tends to contract and empty itself when distended to
a certain point uterus is no exception. In conditions
where the uterus is markedly distended like multiple
pregnancies and polyhydramnios labour occurs
earlier. Uterine distention cannot be the primary
cause as when the foetus dies and the volume of the
products actually decreases usually terminates in
spontaneous onset of labour at the completion of
normal gestation period.
Hormonal Theory: Progesterone is essential for
the establishment and maintenance of pregnancy in
all mammalian species. Csapo proposed an
attractive hypothesis that the progesterone produced
by placenta entails the production of a myometrial
block at the placental site. As the production of
progesterone by the placenta drops, the block is
removed and this withdrawal of progesterone is an
essential prerequisite for the onset of labour in
humans.
Neurohypophysial Hormones: Oxytocin
given to the mother in late pregnancy produces
strong uterine contractions. It appeared logical to
relate the spontaneous onset of labour to
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indigenously produced oxytocin. Blood contains an
enzyme oxytocinase that probably inactivates
oxytocin. There is a drop of this enzyme just prior to
the onset of labour. Experiments showed that there
is secretion of oxytocin both by mother and foetus at
the time of active labour and both are likely to act
synergistic ally. Also, there is a several fold increase
of oxytocin receptors in the myometrium of uterus,
sensitizing the uterine musculature to oxytocin
activity. There is increased oxytocin-like activity in
blood observed during labour and highest
concentration is found during the second stage of
labour.
Prostaglandins: Prostaglandins are
potential myomertial stimulants. At full term,
lysosomes in the decidua become unstable and
release phospholipids which in turn release the
precursors of prostaglandins synthesis. There types
of prostaglandins are produced : PGF2x, PGE2
(prostacyclin). All these were found to increase
during pregnancy and labour. PGE2 probably acts
on cervix reduces its resistance, makes cervix
more soft and ripe and helps in effacement and the
dilatation of cervix during labour. PGF2 is the
effective prostaglandin in spontaneous onset of
labour. PGI2 is a vasodilator and seems to protect
the vascular endothelium from damage during the
powerful uterine contractions during labour. This
may be important to ensure blood flow during labour.
However, whether the rise of prostaglandins
precedes the onset of labour or is a result of uterine
contractions far from clear. The result of uterine
contractions if far from clear. The prostaglandins are
easily metabolized and levels cannot be accurately
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measured in blood. Though uterine prostaglandins
may participate in labour, there is no proof that they
trigger the onset of labour.
Role of foetus: There are many reports to show
that foetal adrenals may be responsible for triggering
the onset of labour. In anecephaly where the
adrenals are very small and in congenital adrenal
hypplasia there is prolonged gestation. In sheep,
prolonged pregnancy results from foetal
hypophysectomy. Also, administration of
corticotrophin or corticosterioids stimulated
premature delivery. Cortisol levels in both foetal and
maternal blood is higher in spontaneous labour than
induced labour or caesarean section. However, in
humans, whether the rise of corticosterioids is the
rigger to onset of labour or the rise is as a result of
stress, is not clear. The role of corticosteroids as the
protective mechanism for maturation of foetal lung is
not clear.
It may be said that all the theories enumerated
above may collectively bring about the onset of
labour. Change in the steroid hormones levels
oestrogen and progesterone at the cellular level,
removal of the progesterone block, building of
oxytocin receptors in myometrium of uterus,
synthesis of prostalglandins due to instability of
lysosomal membranes, production of corticosteroids
and oxytocin by the foetus, all these sensitise the
myometrium to maternal oxytocin and lead to
myometrial contractions causing effacement and
dilatation of cervix. Also, the increase in myometrial
activity is synchronized by synergistic action of
oxytocin and prostaglandins and increased
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intrauterine pressure results in rupture of bag of
waters and in the final expulsion of foetus through
the effaced and dilated cervix. The release of
oxytocin and prostalglandins continues after deliver
and helps to prevent and control any post-partum
bleeding. Thus oxytocin is more important for the
initial phase of labour and increased synthesis of
prostalglandins for the progression of labour. But in
the present state of our knowledge, what triggers the
release of oxytocin is not known (Post graduate
Obstetrics and Gynaecology, 4
th
Edition).
We are still in the dark as to why, in each case,
labour and delivery occur at a particular time on a
particular day. When not expected, suddenly a
patient gets admitted in premature labour and when
everything points out that labour is imminent, the
pregnancy gets postponed and becomes
postmature. Both premaurity and post-maturity can
cause problems for the mother and the baby. Even
in those who advocate delivery by appointment so
called day time delivery, onset of labour can elude
them. The question is often asked as to whether it is
ethical to induce labour for the convenience of the
doctor or the patient, even when everything points
out for successful induction. There is no evidence
that inducing labour in such cases improves the
outcome for mother and baby. Moreover, in some
cases it was observed that the induction may lead to
induction for caesarean section and unnecessary
operative delivery. Hence the conscientious opinion
is that such induction should not be done. In cases
which require genuine induction of labour for any
maternal or foetal condition, labour may fail to occur
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in spite of oxytocin drip or even prostaglandins. Even
in a seemingly normal labour when expected to
deliver early, the labour may be prolonged and end
in operative delivery; while in some others, the
labour may end surprisingly in a very short time.
All these prove t say that we have no control
over onset of labour and the time of delivery. As
described above, still one does not know what
triggers the release of oxytocin for initiation of labour.
These only confirm that conception, onset of labour
and time of delivery are pre-determined and
controlled by the Lord Almighty.
I am reminded in this respect of what Late
Swami Chinmayananda exhorted when giving a
discourse on chapter 15 of Bhagawad Geeta; i.e.
Purushothama Yogam. While explaining the
significance of the sentence Karmanu Bhandhini
Manushya Loke meaning thereby that our past
karmas in the previous birth bind the person for birth
on this earth, he said human beings have no control
over anything in life. We have no control where we
shall be born we have no control over our future
parents let alone the date time and place of
delivery. Similarly we have no control over the time
and the date of death and the manner and the mode
of death. Anything else in life we can cancel or
postpone but not death. No one can come to our
rescue and no recommendations work here. As we
come so shall we go. Bhagwan Shri Satya Sai
Baba. In that context Bhagwan exhorts every person
that they alone can get evolved by prayer, puja,
namasmarana, good deeds and finally, meditation.
As Bhagwan puts it Doctors speak of vitamin
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deficiency. I will call it the deficiency of vitamin G
and recommend the repetition of the name of God
with accompanying contemplation of the glory and
grace of God. That is vitamin G this is he most
important medicine.
Relevance in day to day life : In any hierarchy, be
it Government or any other Institution, if the goods
have to be delivered either for future development
and for the welfare of people or for the progress of
the nation, a coordinated effort by everyone is
essential. For this to occur all blocks have to be
removed that come in the way. Progesterone is good
and essential for continuation of pregnancy and yet
unless progesterone block is removed, normal
labour cannot occur. In the same way there are
many a block in day to day administration. To put it
in simple words it is red-tape that comes in the way
of good functioning. Some projects are shelved;
some work as a block and do not clear the projects;
others do not take any decision let alone clearing
them. Swami Vivekananda exhorted that hard work,
character, conduct, dedication and sacrifice are
essential for the building of a strong independent
India. Initiation of labour pains and the successful
completion of labour set an example of how
coordinated effort of many factors are involved. It is
the hard work on the part of the mother and the
character of the uterine contractions that are
dedicated for the purpose of normal labour coupled
with the sacrifice on the part of he passages
especially the cervix to give up its ego and undergo
effacement and dialatation and the right conduct of
the baby throughout and the judicious management
of the obstetrician that culminate in safe
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confinement. So should be the level of coordination
in the several wings of an organisation for the
completion of any project be the organisation
Government, private, or even personal.
LABOUR
HARD WORK ON PART OF THE MOTHER
If I put one flower at the feet of Goddess I shall
put two flowers at the feet of mother in labour.
These were the remarks of Dr Sudhir Kumar when
as a resident (in my unit), was posted in the labour
ward.
Labour is the process by which the products of
conception foetus, placenta, membranes and
liquor are all expelled entire from the uterine cavity at
term. There are three factors involved in the
physiology of labour:
1. Forces of uterine contractions
2. Passages the uterus and pelvic passages
3. Passenger or the foetus.
During labour because of forces of contractions
the uterus divides itself into two segments upper
and lower segments and the cervix of the uterus
opens up and dilates and the passenger or foetus
descends from the upper segment to the lower part
of the uterus and then traverses through the pelvic
cavity and it ultimately delivered.
True labour is usually heralded by the
contractions of the uterus. These contractions during
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pregnancy are painless and they become painful and
hence called labour pains. They start from the back
and come to the front of the abdomen and go
downwards. In the beginning hey occur after long
intervals and last for rew seconds. They gradually
increase in frequency and duration. In an established
labour 2 to 3 contractions occur every 10 minutes.
Labour is also heralded by the presence of show
blood stained mucoid discharge due to cervix (mouth
of the womb) opening up and the membranes
covering the uterine cavity getting separated from
the cervix.
Traditionally labour is divided into three stages:
First stage is devoted to opening up of the
mouth of the womb called cervical effacement and
dilatation of cervix. The upper part of the cervix
called internal os, gets obliterated and drawn up into
the lower part of the body of uterus and lower part of
the cervix start dilating. At the end of first stage there
is no cervical rim and cervix is one with the body of
the uterus above and the vagina below forming a
parturient canal so that the foetus can descend very
easily. All these changes are brought about by the
strong uterine contractions. The end of first stage
more often than not coincides with the rupture of bag
of membranes.
In the early part of this stage the pain is less
the patient walks about. She may complain of
backache and leg pain. After sometimes the patient
prefers to lie down. As the labour pains become
more frequent and severe the patient in most cases
begins to cry during the pains seeks relief by sitting
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or bend forwards or leaning against some piece of
furniture. Pressure on sacrum gives her slight ease.
Second stage is the stage of expulsion of the
foetus. Not only the uterine contractions become
more strong and sustained, the abdominal and
thoracic musculature are brought into play and the
character of the pains change they become
bearing down pains or expulsive pains.
The patient utters of peculiar cry she feels
that there is a body in the pelvis which she must
force out. She closes her glottis having fixed the
chest in inspiration, braces her feet against the bed
and by powerful action of abdominal muscles drives
the foetal head against the perineum. During
contraction the uterus becomes board-like in
consistency. The parturient is working hard and
indeed the process is rightly called labour. Her
pulse is rapid, veins of the neck stand out, the face is
furgid and the body may be bathed in seat. As the
pain passes off, she relaxes the spasm of the glottis
and diaphragm and takes several deep breaths. She
will request for relief; holds the doctor or the
attendants had tightly begs the doctor to deliver
her immediately even if it means operative delivery.
Excruciating pain occurs with the actual delivery of
the foetal head as the vulva and introitus dilate to
such an extent the perineum stretches up and
becomes thin and nerve endings markedly
compressed.
Third stage is also known as the placental stage
wherein the pain continues, though not in the same
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intensity. After the birth of the placenta the uterus
contracts and retracts so that there is no post partum
haemorrhage.
Labour is work and work mechanically is the
generation of motion against resistance. The forces
involved in labour are those of the uterus and
abdomen which act to expel the foetus and these
must overcome the resistance offered by the cervix
to dilation and the friction created by the tissues of
birth canal during the passage of the presenting part.
In addition the forces of resistance may be exerted
by the muscles of pelvic floor and perineum.
It is this hard work coupled with the pains of the
childbirth (which have been the stock and store of
intimate conversation amongst women since time
immemorial) that many young women approach
childbirth in the dread of the ordeal. It is this fear that
leads to tension and tension in turn causes pain.
These mind and tense cervix go together. It is this
Fear Tension Pain (so called F T P syndrome)
that makes the cervix more resistant to dilatation
which in turn makes the uterine contractions stronger
and cause more pain. Thus Fear is in some way the
chief pain producing agent in an otherwise normal
labour. It is no easy task to dispel this age-old fear
of pain during labour and delivery. While it is true
that the attitude of the woman towards delivery has a
major influence on the ease of labour yet during
pregnancy right from the first parental visit it is he
moral duty of the obstetrician and all persons
involved, to explain and emphasize that labour and
delivery are physiological processes. It must be
explained to her what exactly happens during the
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labour. The obstetrician must instil in her not only
confidence but also the feeling that he is her
medically wise friend, seriously desirous of sparing
her all possible pain within the limits of safety for
herself and her child. The very presence of such a
doctor itself is a potent analgesic. These qualities
result only from the experience of long nights in the
labour room coupled with understanding and
sympathy. They are at once the essentials of good
clinical medicine and the safest and the most
welcome obstetric anodynes. Years before Oliver
Wendol Holmes wrote The woman about to become
a mother or with her new born infant upon her
bosom should be the subject of trembling ease and
sympathy whenever she bears her tender burden or
stretched her aching limbs. God forbid that any
member of the profession to which she trusts her life,
doubly precious at that eventful period, should
hazard it negligently, unadvisedly or selfishly. The
woman in labour is sensitive to every work spoken in
the labour room and any casual remark may cause
worry in her regarding the safety of her child
(Williams Obstetrics-Eastman).
From a philosophical point of view one often
wonders why mother nature had made the process
of childbirth painful and hard work on the part of the
mother. Is it to prove and substantiate the dictum in
Sanskrit Kashtay Phalay (Kashta Hard work,
Phalam Fruit). Unless one works very hard the fruit
of it cannot be obtained or enjoyed. It is pleasant to
see the happiness and the smile on the face of the
mother after hearing the cry of the baby; the
affection she shows when the baby is shown to her
or kept on her abdomen and the tender way she
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touches the baby which gives her the supreme
satisfaction of contributed to the progency in the
family.
Tulsidas in his Ramayana wrote that the
suffering and pain during childbirth cannot be
appreciated by anyone else including an infertile
lady. In Yaksha Prashna of the Mahabharata
Yamadharmaraja, the Lord of Death asked
Dharmaputra, the eldest of the Pandavas What is
happiness? The reply was Happiness is the result
of duties discharged and it should be soul satisfying.
The woman forgets all she has suffered during the
course of labour. She only concentrates on the well-
being of the baby copes with sleepless nights that
follow after the delivery as most of the babies are
awake at night.
If asked how she went through the whole
process she says that she would not like to go
through it again. This is called Prasuti Vairagya.
One only has to see and observe how proudly
the young mother walks holding her child in any
marriage or party with a pride that she has
achieved and brought into this world a live healthy
child. Her esteem in the family increases and the
love and affection and the understanding between
her and her husband increases as the child is the
cementing force.
THE SHORTEST & MOST ARDUOUS JOURNEY
IN LIFE
During the process of labour the foetus has to
pass through the birth canal the pelvis a distance
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of 10 to 12 cms for it to come from inside the uterine
cavity to the outside world. In the first pregnancy the
babys head in most cases is already in the pelvic
cavity and he baby has to travel only 6 Cms
probably the shortest distance a human being has to
travel in life.
Mother nature has taken care to see that no
damage occurs to the baby during this process. The
foetal head is designed in such a way that it consists
of two parts. The base of the skull with strong bones,
in which no changes occur during labour, contains
the brain stem and the floor of the fourth ventricle in
which are the vital centres including respiratory
centre and these are protected. The vault of the skull
in which the cortex of the brain is contained the
bones are laid in membrane, they are not united
suture lines rare present between the bones and
where three or more meet there are fontanelle; the
most important of which is bregma (called anterior
fontanelle). Certain amount of compression of the
foetal head occurs during labour and because f the
pliability of the bones of the vault, no damage occurs
to the brain in a physiological normal labour. In 96%
of deliveries the babys head is low down in he
uterine cavity so that the lower part of the head; i.e.
vertex leads in the journey through the pelvic
passage. Mother nature has also seen that in
majority of women the pelvis the size and the
shape is ideal for childbirth. Pelvis the size and the
shape is ideal for childbirth. Pelvis is broad and
shallow diameters wide enough for the baby to
pass through. At the inlet of the pelvis the transverse
and the oblique diameters are loner and they allow
the head of the baby to get engaged while the
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antero-posterior diameter is longer at the outlet of
the pelvis for easy delivery of the foetal head.
As is well known, no two pelves are he same as
also no two foetal heads. In the same person the
pelvis being the same the size and the shape of
the foetal head vary in each pregnancy and delivery.
Pelvis has its own configuration and angulations as
also the foetal head. It is amazing how the foetal
head adjusts to the pelvis. Firstly, the head which is
already in a flexed attitude becomes more flexed to
allow the small diameter of the head to pass through
the inlet of the pelvis making the occiput lead during
labour. The head also gets moulded by compression
of its diameters for easy passage. During the
descent in the cavity of the pelvis, the head of the
baby takes a rotation by twisting of the next (without
damage) so that the occiput and the vertex of the
head can pass through easily in the anetro
posterior diameter of the outlet of pelvis which is
longer. In the process of delivery the diameters of
the head emerge in such a way that no damage
occurs either to the head or to the maternal passage.
It is this adaptation of the foetal head to the maternal
pelvis ad the various movements the head takes
during the process of delivery which is called
mechanism of labour.
On the part of the pelvis, as the baby is coming
down through the birth canal, the bones and the
joints of the pelvis widen to become more mobile
so that there is less resistance for the foetus and this
is called Give of the pelvis.
In the whole process of labour it is the journey
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of 6 cms (from the ischial spines to the perineum) in
the second stage which is the shortest but most
dramatic and full of events with two main hazards for
the bay i.e. hypoxia and trauma. It is also the time of
greatest physical strain for the mother and the baby
and is aptly called worst journey in the world.
(Apsley Cherry Garrard 1922). But it is also the
grand finale of a process started with fertilization.
Immunologists describe implantation of the fertilized
ovum into endometrium as Immunological
grandioseness. But that we cannot see. Certainly
one cannot but admire (sometimes with awe and
anxiety but many times with pleasure), what a
wonderful phenomenon each child birth is.
It is also a stage that requires a mature
judgement and insight on the part of the obstetrician.
In his anxiety trying to achieve the goal of delivery
over hasty intervention may lead to instrumental
delivery which may be either unnecessary or more
difficult that that what was expected. Extreme delay
may also carry dangers. The object is to strike
balance between expectancy and intervention
keeping in mind that the final delivery method should
be easy and non-traumatic, more so in the presence
of hypoxia and signs of foetal distress.
Fortunately in 90% of all deliveries the labour is
normal culminating in a healthy mother and child. In
10% of cases abnormalities can occur like non
descent of head, non-rotation f the head causing
arrest of head; occasionally the uterine contractions
are no strong enough to push the baby down
through the pelvic cavity or the contractions are
abnormal and strong, causing severe moulding and
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compression of the foetal head producing a caput
(bump on the head) making this shortest journey
ardouous and difficult resulting in operative
delivery.
It should be understood that he foetal head
sustains a pressure compression of 16 lbs in the first
stage and 32 lbs in the second stage of labour
(Munro Kerr & Moir) by the uterine contractions and
also withstands hpoxia which always occurs during
the acme or height of uterine contraction in the
second stage of labour. From a philosophical point of
view Bhagwan has already put the child to test and
certified that the child could stand stress and strain
even through the later stages of life. Bhagwan knows
that life is not a bed of roses. Even if it were so that
rose has thorns. Vicicitudes of life are such that
trauma (need not be physical and can be mental)
and hypoxia (deprivation of anything that is most
essential) can occur any time in life and one should
always be prepared for them. Just like the baby
which could stand the arduous journey, everyone in
life should be geared up for the same with supreme
faith in ones own inherent strength and the
blessings of the Lord Almighty.
Even so it is a common observation that the
female babies stand the strain of this arduous
journey better than the male babies even in difficult
deliveries. This is because they have 44 + 2X
chromosomes which gives them the strength to
sustain the stress. Is it a prelude that women in life
have to undergo many more hardships than men
and that mother nature has endowed them with this
inherent strength or Shakti and the will-power to face
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any eventuality!
VAGARIES OF UTERINE CONTACTIONS DURING
LABOUR
Uterine contractions are synonymous with
labour pains. They are called uterine forces and help
in complete opening up and dilatation of the wombs
mouth or cervix in he early or first stage and later for
the descent and delivery of the baby and also for the
expulsion of the afterbirth or placenta and for control
of bleeding.
The contractile function of the uterus is largely
due to humoral and myogenic factors. Contractions
spread from cell to cell through a syncytium. Gap
junction formation between the cells appears to be a
key to synchronization of uterine contractions. This is
oestrogen dependent and these junctions provide
low resistance pathways for conduction of electrical
activity from cell to cell. Electromyographic
recordings made in women indicate increasing
synchronization with advancing labour.
Study of uterine contractions showed a
physiological coordinated pattern essential for safe
and normal delivery and the features include:-
1. Triple Descending Gradiant
a. All contractions start from the
corneal portion of the uterus on both
sides involving the fundus or upper part of
the uterus and travel to the middle
and lower part of the uterus in 20
seconds.
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1. They are strong and intensity is
more in the fundus.
2. Contractions are more sustained at
the upper part of the uterus and the
fundus.
The above three features called Triple
descending gradient show a fundal domination
during labour.
2. There is polarity i.e. reciprocity between the
uterus and cervix. During the whole course of
pregnancy uterus is relaxed and could expand to full
term and cervix is closed. (If the cervix is to closed or
tight called incompetent cervix, premature
termination or abortion occurs during mid-pregnancy
period). During labour uterus contracts and cervix
dilates.
3. The contractions are peristaltic in nature i.e.
there is relaxation between them. This is essential as
relaxation gives rest to the mother, restores
oxygenation to the foetus and relieves the
compression on the foetal head.
4. As labour progresses the contractions
become more frequent and the duration and intensity
increases.
5. The uterus forms two segments during labour.
The upper segment and the lower uterine segment.
6. The upper segment contracts and also
retracts becomes thicker pushes the baby into
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the lower segment which expands and the mouth of
the womb cervix opens up and dilates fully so that
the baby can pass easily through the birth canal.
7. The pain during labour is due to compression
of nerve endings and also due to resistance of the
cervix to open up and dilate fully. Spontaneous
uterine activity during labour exerts a pressure of up
to 60 mm or even more of mercury.
8. After full dilatation of cervix- the contractions
become more strong and sustained and help in the
delivery of the baby.
ANOMALIES OF UTERINE ACTION
1. PRECIPITATE LABOUR
In rare cases, the uterus becomes over active
culminating in the whole labour ending in 2 3 hours
(normal duration 18 20 24 hours). Such
contractions are no good either for mother or baby.
Trauma to mother and baby and also severe
bleeding from the uterus after delivery occurs as the
uterus loses its power of retraction so essential for
control of bleeding after the delivery of the foetus.
2. INEFFICIENT UTERINE ACTION
Two types of inefficiency of uterine action are
observed:
1. Hypotonic inertia
2. Incordinate uterine action (dysfunctional
labour)
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In recent terminology based on partograms the
above two types from a clinical angle have been
designated:-
1. Prolonged latent phase
2. Primary dysfunctional labour
3. Secondary arrest.
In the Hypotonic Interia the contractions of the
uterus are not strong they occur after long
intervals. They are not helpful in the opening up and
dilatation of cervix thus leading to prolongation of
labour.
In cases of Incoordinate Uterine Action there
is no coordination between one part of the uterus to
the other as in physiological labour. Even though the
upper part of the uterus; i.e. upper segment is
contracting well the lower part of the uterus i.e.
lower segment is hypertonic tense and does not
expand. In other cases though the two segments are
contracting well, there is spasm of the cervix and it
does not open up or dilate a condition called
cervical dystocia. Very rarely contractions occur in
different parts of the uterus they are colicky in
different parts of the uterus they are colicky in
nature and the mother is distressed with severe pain.
All these again cause prolongation of labour.
One of my teachers used to compare these two
types of inefficient uterine action to two types of
students (Medical or otherwise). In the hypotonic
type the uterus is sluggish takes it own time to get
back to normal activity. It is like a student who does
not attend the classes does not read spends his
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parents money and whiles away his time and takes a
long time to complete his medical or any other
course. Instead of 4 years I may take as long as a
6 to 7 or even more years for a student to complete
the medical course. Some of the students
occasionally grace the lecture class only to see and
certify whether the teacher is properly doing his job
or not.
The hypertonic type is compared to the second
type of student. Hese students are always regular
attend all classes study in the library for a late
period at night. In their anxiety to score well and get
good rank or high percentage of marks (as
unfortunately this is the criteria for getting admission
o the desired course or subject for post-graduation).
These students are always under tension and worry
and they cannot concentrate. Even though they
know he subject, yet their performance in the
examination is poor and some may even fail in the
examination thus taking a prolonged time in
completing the course. It is this type of students who
often resort to drugs etc., and/or commit suicide due
to frustration.
The treatment for both these types of students
is the same as in the two types of uterine action. The
hypotonic uterus requires a whip or stimulation for
good performance. While in cases of incoordinate
uterine action or dysfunctional labour sedation to
relieve the tension is given first, along with advice
and encouragement for study.
The normal and abnormal uterine action point
out to another important observation in todays
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working of persons. Either in Government or in any
concern, for efficient running or working the
coordination of the entire staff is essential. In
physiological normal labour, the fundus of the uterus
is dominant while the lower segment and cervix
cooperate with it. In the same way there should be
one head to control and coordinate all the activities
of a department or an Institution. I the hypertonic
lower segment or cervical dystocia, the fundus of the
uterus in working normally but the lower segment
and cervix do not listen to it. They have developed
tension in their heads do not cooperate with the
fundus behave in a different way leading to
prolonged labour requiring operative delivery at
times. It is a common observation in these days of
deteriorating standards when each institution or
department have become Samsthans
(conglomerates) the staff in these departments
come late to the office, are either lazy and do not
work as in cases of hypotonic uterine interia. Others
who become proud and arrogant do not cooperate
with the superiors and cause obstruction for proper
functioning. Both these two types of people if
advised to correct their behaviour accuse the
authorities for harassing them.
I am reminded of how my Professor of
Physiology classified his assistants 1. Equine quick
and sure, 2. Assinine slow and steady and 3.
Elephantine dull and non- co-operative.
It is in the primi gravid patient that anomalies of
uterine actins are more often observed. The primi
gravida approaches labour with apprehension
hearing the experiences of others like one who had
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a prolonged labour, or still birth (baby died during
course of labour) and/or an operative delivery. All
these tell upon her mind and cause fear of the
unknown. Fear in turn lead to tension in mind and
tension causes pain. A tense mind has always a
tense cervix and/or lower segment. Tense lower
segment does not expand and tense cervix does not
dilate leading to cervical dystocia. Ultimately they
end in prolonged labour and operative delivery. Such
labour is observed in highly educated, nervous and
high strung persons but not in rural people and
tribals. These people take pregnancy and childbirth
as a physiological process as in everything else in
life. Faith and supreme confidence that she will have
a safe confinement in her Obstetricians hands will
go a long way in minimizing these types of
anomalies of uterine action.
At times one often wonders and becomes
perplexed as to why the pregnant uterus should
behave in this way during labour. Where one
expects a prolonged labour, the labour is so smooth
and easy. In others when everything is normal, there
are no contractions at all or they are incoordinate or
in the beginning of labour they are normal and strong
but half way through interia occurs and there is
arrest of labour.
A helpless obstetrician often feels like doing
puja to the uterus and request for strong contractions
and the cervix to dilate a little more so that the
babys head can come down and delivers normally. I
often wished that if only I could recite an Ashtottara
(108 names recited in the praise of the Deity) of the
Goddess uterus to help me out of this impasse.
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A common misconception is that women in
general are unpredictable in their behaviour. Do the
vagaries of uterine action reflect the nature of
women? Observations however show that men are
even more unpredictable and unbelievable than
women. In short, the vagaries of uterine contractions
points out the nature of the human behaviour
observed in day-to-day life. My Professor Late Dr
Thampan used to compare the uterine contraction as
the most unpredictable factor in labour.
Presentation, position and pelvis may be normal,
but pains may fail! He used to say, No one can
predict the minds of women or the luck or prosperity
of men and finally, the contractions of the uterus!.
BABY IN THE WOMB - MY GURU
In over 96% of pregnancies at the time of
onset of labour the babys head will be low down at
the upper part of the birth passage. Also the baby
lies in a way that the back of baby is arched and lies
anteriorly and the head of the baby is flexed, so that
the chin is nearer to chest (sternum) all the parts of
baby are close to one another. This above is said in
obstetric language Attitude of Universal Flexion
and the presentation of baby called Vertex
presentation. (Vertex is the area between the
anterior fontanelle (maadu in vernacular) to the
occiput behind and on both sides the parietal
eminences). During the course of labour the head of
the baby still flexes so that he smallest diameter of
babys head passes through the pelvis, the occiput
leads and by this normal delivery is achieved.
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In 10% these vertex presentations, the back of
the baby is posterior and the occiput lies near to the
maternal vertebral column, (called occipito posterior
position). In this the back of baby will be straight (not
arched as in the above), and this attitude of the baby
is called Military Attitude. Consequently the head of
the baby cannot be completely flexed and slightly
longer diameter of the head presents at the birth
canal at the onset of labour. In cases where the
delivery ends normally, the head of the baby gets
flexed, small diameter engages the birth canal,
though the length of the labour will be slightly
prolonged. In some, the labour may become
arrested and end in operative delivery.
(a) Flexion Humility
(b) Partial Flexion Ego Military
Attitude
(c) Partial Extension Indifferent
Arrogance
(d) Extension Gazing Stars Arrogant
Rarely the head of the baby lies in a more
deflexed attitude and this presentation of the baby is
called Brow (he forehead lies lower most) and
normal delivery is impossible in this and baby has to
be delivered by Caesarean section. When the head
of the baby is completely extended it results in Face
presentation. Though occasionally the delivery can
be spontaneous yet many end up in operative
delivery.
All the above only shows that the baby in the
uterus knows what is good for it for safe delivery. By
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adopting the attitude of flexion, labour ends safely in
respect of both mother and itself.
Even in those cases where the buttocks of the
baby delivery first called Breech delivery the
delivery is more smooth if the head of the baby
which is delivered last is in an attitude of flexion. If
the head is extended (not flexed) called Stargazing
foetus labour will be more complicated and hence
requires Caesarean section.
Years ago, during my training period my
teacher Late Professor Dr. R.K.K. Thampan
impressed upon us the importance of Attitude of
Flexion in ones daily life. He said that everyone
should adopt this attitude of flexion. He compared
the medical students in their training period to the
baby in the uterus. The first MBBS 1 years to
the first trimester of pregnancy, second trimester the
next 1 years and the third trimester to the last 1
years. Students with the flexion attitude have smooth
course throughout and at the final examination have
a safe delivery. In those who do not observe this, the
students will have to pass through a prolonged
course failing in he examinations. Of course, some
of students are being salvaged by the examiners by
application of forceps.
What has been said regarding the medical
students applies to all of us. While walking, if the
head is not flexed one may miss to see something
below may slip on a banana peel, or fail in a it; all
these happen definitely in those who adopt a military
attitude as in occipito posterior and one can
imagine what will happen to those who walk with a
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head looking high up stargazing.
If one views the above philosophically, with a
Vedantic aspect, - when one thinks of flexion attitude
it is not only related to the body but also related
to the attitude of mind. Flexion attitude refers to
vinayam (bent of mind with humility) God fearing
and respect to elders. Unfortunately one does not
observe this attitude in people now a days. It is all
the more sad that some students after graduation, or
more so after post graduation, change their attitude
towards their own teachers. In life, many who come
up and reach a top position become head strong
and think no end of themselves.
I had been conditioned to observe this attitude
of flexion every since the early part of my training in
obstetrics. I was applying forceps to deliver a baby
whose mother was having eclamptic convulsions. I
could not apply the blades when the senior sister of
the labour ward pointed out that the presentation
was Brow. I could not make that out. The difference
between vertex and Brow is such as pointed above
one of slight deflexion of the head. In vertex vaginal
delivery can be accomplished and for the brow
Caesarean Section had to be done. (Of course, the
baby was delivered by the procedure of turning the
baby called internal podalic version as it was in
vogue at that time). From that time, all these years I
have learnt many good things from every one right
from the aaya, assistants and nursing staff in the
labour ward and the operation theatre, students, post
graduates, colleagues and from seniors. Good things
can be learnt from any one in life if one looks for
them.
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I always felt that the post graduate training
should be like that of discourse between the teacher
and the taught, like Krishna-Arjun
Samvaada (discourse) as in Bhagwad Geeta. The
teacher should not get upset when he findings of the
post graduate become correct on the operation
table. Some of the pos graduates may later
specialise in a particular field and the teacher should
not feel below dignity to learn a new procedure from
his own student. Nor the student should feel proud
and assume a military attitude. After all, learning is a
continuous process and there is no age bar for it. I
am always reminded what Late Dr S Radhakrishnan,
one of the greatest philosopher cum statesman our
country ever produced said A good teacher is
always a good student and if he ceases to be a
student, he ceases to be a teacher.
This throughout my professional experience till
today the Foetus has been my Guru. Bhagwan has
taught me to follow the baby in the uterus. Whenever
I changed this attitude due to ignorance or pride or
ahamkara I used to get a hit on my head telling me
to keep my head as well as my attitude flexed.
Bhagwan Rama Maharashi said that if one has
to evolve and achieve moksha one must Erase the
Ego or Ahamkara and an attitude of flexion is very
essential for this. It is said that the Ahamkara or Ego
for any human being is in their hair. People in the
south offer their hair (by getting the head completely
shaved) to the feet of Lord Ventateswara. In so
doing they are offering or submitting their ego.
Whenever one pays his/her respect to elders it
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is always with head in full flexion, the brow touching
the forehead on all devout muslims who regularly
perform Namaz is the best example of this act of
obeisance.
Regarding he importance of the attitude of
flexion the great Obstetrician Ian Donald wrote For
a successful delivery an attitude of good flexion on
the part of foetus is essential. Flexion is the essence
of normal labour (nay essence of life). In flexion after
all, we come into this world and bent up in old age,
we go in flexion to our graves. Flexion is the alpha
and omega of life it is the beginning and the end.
WHAT DO THE FIRST BREATH AND CRY OF
BABY INDICATE
Normally as soon as baby is born it starts to breath
and more often than not, to cry. By ultrasound
studies, it is observed that foetal breathing
movements do occur even during pregnancy and it
has been suggested that these may be associated
with lung maturity. All factors involved in the first
breath of the baby have been difficult to elucidate.
Undoubtedly subtle stimuli contribute simultaneously
for the same.
(a) Physical stimulation such as handling the
infant during delivery and contact with
relatively rough surfaces provoke respiration
through stimuli reaching the respiratory centre.
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(b) Compression of the thorax during second
stage of labour forcing some fluid from the
respiratory tract and the expansion that follows
delivery may be an auxiliary factor in initiation
of respiration.
3. However it is the deprivation of oxygen and
accumulation of carbon-dioxide that may stimulate
respiration. Experiments have shown that
intrauterine decrease of pO2 diminishes or abolishes
respiratory movements, whereas elevation of pCO2
increases the frequency and magnitude of foetal
breathing movements. For the foregoing reasons the
foetus-infant in fact most likely responds to hypoxia
and hypercapnia (which occur during second stage
of labour) the same way in utero and after birth.
(Williams Obstetrics 1993).
Thus, a babys first breath is a remarkable
phenomenon and it clearly calls for a very great and
intensively concentrated effort. If this does not occur,
the baby develops the condition of asphyxia which
may cause is death. Even if the baby survives, it
may be left with a legacy of disorders. There may be
only delay in the normal milestones regarding growth
and behaviour of some infants. Others manifest
convulsive states, mental deficiency, spastic
paralysis, ataxia and disorders of speech etc. In the
intellectual field all gradations from mental
backwardness to personality disorders and epilepsy
may originate from lifes first critical quarter of an
hour and the obstetrician resuscitating the new born
is fighting not only for the childs survival but for its
very wits (Ian Donald).
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While the onset of first breath is explained as
above, no proper explanation is given for the babys
first cry. Why should it cry t all even as every one is
happen at this event of hearing the first cry? One
cannot forget what Shakespeare in King Lear says
When we are born we cry that we have come to this
great stage of Fools but he is nearer the
physiological explanation when he adds that the first
time when we smell the air, we wail and cry. Poet
John Keats in Ode to a Nightingale wrote that the
child cries as it gets aware of the sory state of the
world in which it is emerging a world
Where men sit and hear each other groan
Where but to think is to be full of sorrow.
There is a famous saying in Urdu which runs
When I came into this world, I cried and others
laughed. Now when I leave this world I must laugh
and others must cry
It is written in the Bhagwatam that while in the
garbhashaya (womb), that the jeeva (foetus) sees
the Brahman (Lord and prays to the Lord to grant
him His darshan after birth. Unfortunately after birth,
he cant see the Lord and so he cries kahan kahan
(Where is He? Where is He?). If one closely
observes the cry of the new born and that of a child,
there is a difference in the type of cry. The cry of the
new born is more like Kau Kau instead of Bau
Bau of the child. Bhagwan Sri Satya Sai Baba in his
divine message says that in the babys first cry the
baby is saying Ko-ham meaning Ko = who; Ham = I
am that is who am I? and Bhagwan adds that lifes
purushartham (purpose) is to realise So ham;
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i.e SO = That HAM = I am; i,e, - That I Am. In short,
ones life objective is to realise That Thou Art!
On this first cry of the bay, Bhagwan Gautam
Buddha preached:
Ask of the Sick The Mourners Ask of Him
Who Totereth on HIS Staff Lone and Forlom
Liketh They Life; They Say
The Baby is Wise Weepeth Being Born
..Light
of Asia
These preachings were given years ago. They
are more valid today than even before. The child at
birth knows what is in store for it in this world a
world full of deceit, corruption where sincerity and
hard work have no place; where muscle power and
money power are the pillars of strength and can
achieve anything in life. The baby is also aware that
there is no escape and ones own birth is due to
ones own past karmas as said by the Lord in the
Bhagwad Geeta (Chapter 15):
Karmanubhandhini Manushya Loke.
It may be that keeping these in mind Bhagwan
Adi Shankaracharya in Bhajagovindam requests the
Lord to save mankind from the samsara of births and
deaths.
Punarapi Jananam Punarapi Maranam
Punarapi Janani Jathare Shayanam
Iha Sansare Bahu Dukkhare
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Kripaya Pare pahi Murare
Birth again, death again
Again laying in the womb of the mother
In this world full of misery
Kindly protect me by Your bliss
O Lord! I am under your shelter.
STILL BIRTHS & NEONATAL DEATHS:
DUTY OF THE OBSTETRICIAN
Published studies on still births and neo-natal
deaths indicate that many women who had peri-natal
deaths wished that they would have liked to have
been told of their babys death when it occurred.
They also expressed that it would have helped them
to bear the loss if the doctor had explained why their
babies had died. Many felt dismayed when the junior
doctors in the hospital intimated the same instead of
the senior doctor, Grief reactions in these patients
showed emptiness, restlessness, numbness,
sadness, fatigue, shock and disbelief; loss of self
esteem, and self blame for disappointing their
husbands and everyone in the family and doubted
whether they will ever be able to have a baby. In
some cases, being under anaesthesia or heavy
sedation at delivery, mothers had not seen or
touched the baby in cases of still birth.
In most cases there may not be any warning
during pregnancy that he baby might die. Because of
societys abhorrence of a still birth she may feel
being avoided by the doctor, husband and the in-
laws and friends and a feeling of isolation occurs. In
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cases of neo-natal deaths mothers never forget
sequence of all the events from the birth of the baby
to its death and this includes the role of the doctors,
nurses, attendants and everyones behaviour and
attitude. Perinatal deaths may even affect the
surviving children at home. When the parents are
depressed, preoccupied and irritable, the children
feel abandoned and unloved. They conceal their
emotions when told that the baby was Taken by the
God or asleep to account for the babys absence.
Women who have lost their babies in the
perinatal period need help. Telling the parents about
their childs death should not be postponed. Ethically
and morally it should be done by the obstetrician
himself or otherwise they will lose their faith in him.
Simple explanation of why the baby died may help to
relive guilt and may allay fears about the future. In
cases of unexplained intrauterine deaths one may
not be able to find out the cause. However all
questions should be answered patiently and they
should be assured that nothing he/she did (or failed
to do) was the cause of the death. Sympathy and an
understanding attitude, may help the bereaved
couple to tide over the mourning period. After some
period, meanwhile allowing the mother to readjust
from the thinking of herself being incomplete and
deprived of fulfilment, the couple should be
suggested to have another pregnancy; i.e. So called
replacement child syndrome (Poznaski 1972).
It again shows that in spite of all the care taken
by the obstetrician mishaps do occur even in the
best of hands as there is one Super Power beyond
our conception which guides the destiny of all of us.
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Thus he obstetrician will also have to face not just
moments of pleasure all the time but also of pain as
well, as pleasure and pain (sukha and dhukhkha) go
together. Such cases are a test for him only to make
him more mature and understand the need for
meticulous attention required in every case right
from the beginning of pregnancy till safe delivery. It
also calls for a great control, restraint and
understanding on the fellow obstetricians and they
should try to place themselves in a similar situation
before pronouncing their opinion. (This applies
equally in cases of maternal deaths).
After all the care the obstetrician bestows, it is
He that ultimately decides. As they saying goes, We
treat - He cures.
EACH PREGNANCY & CHILDBIRTH IS
A REBIRTH FOR THE MOTHER
(The inherent Risks of Pregnancy to the Mother
are not well appreciated)
Years ago, the daughter of a famous
obstetrician died of acute rupture of ectopic
pregnancy (pregnancy in the fallopian tubes) even in
the first pregnancy. A colleagues daughter whose
pregnancy was apparently though to be normal,
developed convulsions (eclampsia) due to sudden
rise of blood pressure. In clinical practice it is to
uncommon to observe prolonged labour or
obstructed labour ending in operative delivery
some times resulting in the death of the bay (still-
birth) or even death of the mother.
Such cases are seen today in patients who had
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no ante natal care and admitted to the hospital as
emergency cases (unbooked cases) especially in
semi-urban and rural areas.
The delivery can be obstructed because of the
malposition and presentation of the baby and the
uterus can rupture due to a large sized baby or
cephalopelvic disproportion even of a mild variety.
After a very easy vaginal delivery the uterus may
become atonic (there is no contraction or retraction
of uterus essential for control of bleeding at this
stage). The patient can die of severe post partum
haemorrhage. In a matter of few minutes so much
blood can be lost leading to shock and collapse of
the mother. The often quoted example is that of
Empress Mumtaz, wife of Emperor Shah Jahan who
died of severe post partum bleeding at her
fourteenth confinement. This is indeed the
unforgiving stage of labour and there lurks more
unheralded treachery than I both the other two
stages combined. The normal can within a minute
become abnormal and a successful delivery can turn
swiftly into disaster.(Ian Donald). Very rarely sudden
death can occur due to amniotic fluid embolism.
Deaths due to puerperal infection were very common
before the advent of the antiseptics and antibiotics.
However the above risks usually occurred in
women who had a parity eight or more and these
women were designated Grand Multiparae or
Dangerous Multiparae. Unfortunately these dramatic
complications are all the more dangerous because
they occur unsuspected.
With the adoption of family planning one may
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not see such Grand Multiparae as before. Even so in
rural areas or taluka places still women with parity 4
or 5 are encountered and in them the above
mentioned complications are observed. Munro Kerr
and Moir wrote Robustness of body and mind,
however is no insurance against the disturbances
and complications of pregnancy and child birth. And
that parity beyond four is associated with ever
increasing dangers.
When the first pregnancy and delivery were
normal people and patients think that everything
will go on well in the second and subsequent
pregnancies. As the number of pregnancies increase
the incidence of anaemia is more than double,
hypertensive disorders increase, haemorrhages of
all varieties e.g. abortion, ectopic gestation, vesicular
mole in early weeks, placenta praevia and abruption
placenta in later weeks are more commonly
encountered. In short any complication can occur at
any time unexpectedly. The obstetrician should be
on the watch for any eventuality from the time a
woman misses the period till she delivers safely. The
course of pregnancy and delivery each time may be
entirely different from the previous one. As our
elders have aptly described that safe pregnancy and
child birth gives the women Punar-Janma or
Rebirth and this applies to each and every
pregnancy. Also nothing is more apt than what
Solomon (1934) wrote 60 years ago that Practice
makes a person perfect does not apply to pregnancy
and child birth.
Having done clinical trials personally regarding
the usefulness of Prostidin. (15-S 15 Methyl PGF2- )
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in the prophylaysis and treatment of post partum
haemorrhage, I feel that it is the moral duty of all
obstetricians to keep not only the above drug but
also other essential drugs handy at all times in the
labour room.
Increasing experience serves only to sharpen
ones attitude during this stage and there is no room
for complacency in any case, however normal, until
the placenta has been delivered for at least half and
hour with the uterus well contracted and with minimal
bleeding (Ian Donald).
Then only can one aspire for and ensure Safe
Motherhood.
PRE-PREGNANCY CARE : THE NEED OF THE
DAY
No aspect of the subject of obstetrics and
gynaecology will be complete without a
consideration regarding pre-pregnancy case. In
order to achieve the goal Health for All, actual care
and preparation of the parents for child bearing
should start before conception i.e. pre-conceptional
or pre-pregnancy care. The obstetrician will have a
clear idea of the couples biological and social
background, race and genetically inherited
propensities. If the physical examination reveals a
medical condition, the couple and the doctor can
discuss the likely effects on the pregnancy when it
occurs and also on the progress of the disease
process. It would help a lot better if proper advice is
given before pregnancy. Once pregnancy has
started, there will be only two options left for the
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couple either to let the pregnancy continue or get it
terminated. If the consultation could take place
before pregnancy started, the couple may elect to
remain childless, thus completely avoiding the risk.
There are some couples who are having a very
happy married life and are content without having
any children. Their love and affection is such,
childlessness will not affect them. Many others may
adopt a child to satisfy their maternal and paternal
love.
In some well developed countries pre-
pregnancy care has become apart of health
education and is being advocated right from the
school-going period even before the girls get
married. The care also includes advice regarding
diet, anaemia, heart disease (haemotogical
problems), alcohol and smoking in a few, or sex
education and contraception and the importance of
pregnancy spacing when they do have children. An
equally important aspect of the care pertains to the
effect of infections like German measles,
toxoplasmosis etc. on pregnancy and also sinister
effects of sexually transmitted diseases like
gonorrhoea, syphilis and even AIDS (Acquired
Immuno Deficiency Syndrome) on their health if they
become pregnant, and the effects on the offspring.
In married persons, advice pertains to recurrent
foetal loss due to congenital abnormalities or
previous pregnancy ending in late abortion or early
pre-term labour and the chances of the baby getting
Downs Syndrome in a mother in late reproductive
age. Such an advice given or taken in this field
produces rewards equal to (or even more than)
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those resulting from ante-natal care.
In one report concerning cases of diabetes with
pregnancy, pre-pregnancy care involving tight
control of maternal blood glucose concentration
before and in early weeks of pregnancy, has given
good dividends in a highly significant reduction in the
risk of serious congenital abnormalities in the
offspring.
As a logical sequence of this pre-pregnancy
care, it is also obligatory on the part of general
practitioners, physicians (for that matter every
consultant in medical field) and obstetricians and
gynaecologists in particular, to tell the parents or
even the to-be-married girl or boy, if sufficiently
mature and grown up, and advice them against
getting married when they are found suffering from
some incurable disease or defect or have severe
medical or surgical problems like heart disease etc,
which may endanger their life. A considered opinion
of the specialist in different fields of medicine should
be taken before hand.
Unfortunately there is a tendency amongst
parents to hide any defect in their children before
marriage and somehow get their children married
only to end in disastrous results, ruining the life of
the boy or the girl or both. Many marriages are
broken in a short time; still worse, many have
become widowed at a very young age. Sometimes in
the case of the girl, they are either pregnant or have
just delivered. Indeed it is very sad to hear about
such cases and one just cannot imagine what the
future of the girls would be. There is an old saying
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One can tell one hundred lies if that is going to help
in getting someone married. Such a thing is immoral
and unethical and the present motto should be It is
only right and correct that one should tell the truth to
the parties concerned and prevent (in fact he is
helping them) such a type of marriage. Thus pre-
pregnancy care is the first step in the right direction
for safe motherhood.
Late Dr. D. Subbarao, Professor of Hygiene
(Preventive and Social Medicine) stressed the
importance of pre-conceptional conferences nearly
fifty years ago when I was a student at the Andhra
Medical College Visakhapatnam.
BREAST FEEDING : BREAST MILK IS BABYS
BIRTH RIGHT
A calf after its birth, even as the mother cow
cleans it by its tongue, though not able to stand
properly, tries to get up and goes straight to the
udder and to drink milk. Who has taught it where the
udder is? certainly not by practice but by
Sanskara (inherent tendency); i.e., certain things one
brings along with oneself with birth. Breast feeding
is a natural sanskara and breast milk is babys birth
right.
Apart from other things, three aspects of life
have been specially mentioned which bless both the
one that gives and one that takes. The first is
Daan (parting with what one has without repayment)
especially vidyadaan (parting with ones knowledge):
where the teacher and the taught are both blessed
and there is no reduction of knowledge by it. The
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second is Mercy. As Shakespeare wrote in the
Merchant of Venice The quality of Mercy is not
strained; it is twice blessed; it bless him that gives
and him that takes. The third is duty. Conception
and childbirth are part of duty, without expecting any
reward. But beast feeding is a duty where mother
and child are not only blessed but also benefited.
Immediately after birth, breasts secrete a
yellowish thick fluid called Colostrum. A new born
does not need anything other than colostrum. It is
rich in vitamins A and K, and contains many
antibodies which give the baby its first
Immunization to protect it against most bacteria and
viruses which may cause life threatening infections.
It also contains growth factors which stimulate a
babys immature intenstines to develop and to digest
and absorb milk. Colostrum is also a laxative and
helps the baby to pass meconeum (the first dark
stool) which in turn helps to prevent jaundice.
Colostrum also protects the baby from getting
allergic disorders like asthma and eczema later in
life.
Breast milk is the ideal and inimitable milk and
is the sheet anchor of nutrition. Throughout the first
4-6 months of life, breast milk safely and adequately
meets all nutritional needs of the infant. The amazing
part is that more suckling by an infant makes more
production of breast milk.
Apart from being hygienic and sterile breast
feeding is cheaper. It costs eight times more to feed
a baby on a formula and four times more to feed a
baby on cows milk in comparision to breast milk.
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Non breast fed infants are 11-16 times more likely
to die from diarrhoea, 3-6 times more likely to die
from respiratory ailments and 2.5 times more from
other infections, when compared to breast-fed
infants.
On the part of the mother, breast feeding helps
with involution of the uterus and helps the mother to
regain her figure faster. Cancer of the breast and
ovary is less likely in mothers who breast feed
compared to those who do not. Breast feeding can
delay the return of ovulation and menstruration.
Hence, it is an important way to delay a new
pregnancy. Lactational Amenorrhoea of family
planning (LAM). Years ago, when the concept of a
small family was not in vogue, breast feeding and
lactational amenorrhoea helped many women to
space their families. I recall quite a few patients had
menstrurated only for a few times during their
reproduction period as lactational amenorrhoea is
usually followed by the physiological amenorrhoea of
pregnancy.
In addition to the above benefits to mother and
child, breast feeding helps the mother and baby to
develop a close loving bond. This goes a long way in
helping a child to develop normally in every respect,
especially its attitude towards others in terms of give
and take and a good relationship. Even on the part
of the mother, as a saying in Telugu goes more than
kanna prema, the penchina prema is greater which
means that the love and affection of a other who
breast feeds a baby and brings it up is said to be
much greater than the affection of a mother who
delivers a baby and does not breast feed. The oft
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quoted example refers to the prema or love and
affection and tyaga of Yashoda who had breast fed
Lord Krishna and brought him up is far greater than
that of mother Devaki who delivered Lord Krishna
but unfortunately could not feed him and bring him
up.
However, successful breast feeding depends
upon the well being of the mother and her nutritional
status. Most mothers in our country are
malnourished and anaemic. Nutritional supplements
with iron and calcium and a balanced diet are of
utmost importance for safe motherhood and
successful lactation.
Inherent attitude and a positive approach of
mother (and would be mothers) for breast feeding is
equally important. Many of our educated and
working women want to do their best for their
children. What they lack is information on the
benefits of breast feeding and also the practical
advice as how best to integrate breast feeding in
their modern lives. Such an education should be
imparted to them by everyone concerned with
maternal and child health care.
It is gratifying to note that so much is written in the
lay press about the benefits of breast feeding and
the encouragement given to the slogan Breast
feeding is the need of hour. The Government of
India and agencies like UNICEF have taken concrete
steps so far in promoting the same yet if what is
suggested below is observed, it would go a long way
in the success of the programme:
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(a) All working women should have paid
maternity leave for a minimum of six months
after delivery. This itself would go a long way in
restoration of maternal health after delivery and for
successful lactation.
(b) Provision of crches at places of
employment so that women can breast feed
their babies during working breaks.
(c) For working class, employers should make
it easier rather than more difficult for
breast feeding women to work, especially in
arranging working hours.
Establishment of Human Milk Banks is in vogue
and in some states have been started, and human
milk is being stored for selling purposes. Ethically
and morally one feels a bit sceptical unless these are
run with all the care that is required and Government
should regulate the process, before they become a
menace too difficult to contain, as in case of semen
banks.
In the end it must be stressed and emphasized
that breast feeding is time honoured and not old
fashioned and to breast feed a baby is a natural
instinct on the part of women. If one observes an
infertile woman taking a small baby in her lap, she
puts it very close to her breast and hugs it. In some
cases, even secretion of milk occurs when they feed
a baby, let alone the recurrence of secretion of milk
after a long gap in women who have had children
before. In mothers who are actually feeding, with the
cry of the baby the intense desire makes them
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produce milk instinctly even before suckling of the
baby; even the baby recognises the mothers touch
and stops crying immediately. The intense desire to
breast feed transgresses even the species. There
are on record occasions where dongs have breast
fed kittens and wolves have breast fed an
abandoned human child and brought him up.
Whatever it may be, as our elders have
stressed, that breast milk is the best for the baby and
only confirms the oft quoted saying
SEX DETERMINATION & SEX DIFFERENTIATION
Sex of an individual is a hereditary trait and
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depends upon the nature and structure of the
chromosomes of the fertilized ovum. The number of
chromosomes contained in the cell nucleus is
constant in every species; e.g. in man every cell
contains 22 pairs of autosomes (or body
chromosomes) and one pair of sex chromosomes.
Both egg and spermatozoon undergo a reduction
division for maturation which leaves them with half
the number of their original chromosomes. In the
human species the two sex chromosomes in the
female have identical structure (termed XX) but the
structure of chromosomes in the male differ (termed
XY). It is therefore obvious that after the maturation
division all the eggs would contain 22 autosomes
and one X chromosome while he spermatozoon
would contain 22 autosomes but either X or Y
chromosome. If the fertilizing spermatozoon is X
containing, the embryo will possess the cells with a
pair of XX sex chromosomes and be a genetic
female. Impregnation of an ovum by Y containing
spermatozoon produces a cell with a pair of XY sex
chromosomes, thus determining the development of
the embryo as genetic male. According to this
concept sex determination in humans depends upon
the structure of the sex chromosome in the fertilizing
spermatozoon and not on the nuclear structure of
the ovum.
After the sex is determined by the chromosomal
mechanism, the unravelling of the anatomical sex is
done by the process of sex differentiation. The
process of sex differentiation has two phases:
(a) Differentiation of the gonads
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(b) Differentiation of the accessory sex
organs.
Normally in accordance with the genetic sex, an
orderly sequence of changes bring about
transformation of a bisexual embryo into either a
male or female.
Round about5-6 weeks of intrauterine life,
whatever the genetic sex of the embryo may be - the
first gonadal primordium that appears has two major
components; viz. the outer cortex and the inner
medulla. The cortex has a potentiality to develop into
ovary and the medulla has the potentiality to develop
into testis. These two components produce inductor
substances which in turn are controlled by male
determining genes M present on the autosomes and
Y-chromosome and the F for female
determining genes present on the X-chromosome.
At the time of fertilization there is established in the
zygote a complex of genes in which quantitative
superiority of the female or male genes determine
the sexuality of the individual. In other words it is the
genetic balance that plays the determining role in
deciding which component in a given individual
should differentiate to form a gonad. Normally in
genetic male the medulla develops into a testis. In a
genetic male round about 7
th
or 8
th
week of
intrauterine life Y-Chromosome and the male
determining genes on Y-Chromosome produce a
substance known as H-Y antigen (formally called
Testicular morphogenetic hormone) a plasma
membrane protein and this is closely related to
testicular differentiation. When the testes develop
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and function normally in an early embryo the embryo
will develop as a male. Should the testes be absent
or if they do not function normally the embryo will
become a female morphologically whether ovaries
are present or not. It would be realised that male
development is concerned with having testes and
female development with not having testes.
Testes carry out their intrauterine function by
producing two substances:
1. Testosterone
2. Anti-Mullerian hormone.
In every individual, there are two types of
system of ducts present Wolffian ducts are
responsible for the development of male accessory
sex organs and Mullerian ducts for the development
of internal genital organs in the female i.e. uterus,
fallopian tubes, broad ligaments and upper three
fourths of the vagina. The external genital organs in
the female are developed from urogenital sinus.
In the male, the testosterone gives rise to the
development of external genitalia and the Wolffian
system whilst the anti-Mullerian hormone inhibits the
development of Mullerian structures, which are
always present and capable of development. Anti-
Mullerian hormone is a glycoprotein produced by
sertoli cells of the testes. Anti-Mullerian hormone
has a unilateral action so that each testis appears to
produce the hormone which results in the regression
of the Mullerian structures on its own side. The
sensitivity of the Mullerian structures to anti-
mullerian hormone is present only during the first 8
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weeks of gestation.
To utilize testosterone effectively the external
genital organs must convert testosterone into
dihydrotestosterone through the action of an enzyme
5- -reductase it is necessary for these substances
to be bound to receptors in the cytoplas of the cells.
Hence, deficiency of 5- -reductase and ineffective
binding of testosterone lead to abnormal sex
differentiation known as androgen insensitivity and
this can lead to intersex problems.
It is a traditional belief among our people that
they must have at least one son in the family not
only to keep up the family name but also to save
hem from a particular kind of Hell called in Sanskrit
punnaamanarakam. It is also ingrained that the son
only should lit the funeral pyre of the parents when
they die. It is for the above reasons that those who
do not have any children do lot of pujas and prayers
and observe austerities so as to evoke the
prasanna of the Lord to bless them with a son.
However, sex of the baby in the womb is
determined by which of the sex spermatozoon meets
the ovum and fertilizes it. If one containing Y
fertilizes the ovum the resulting child will be a male.
If the one containing the X fertilizes, the child will be
a female. Nobody can predict except perhaps those
with super-natural powers what will be the sex of the
future baby. It does not depend upon the wife; nor
does it depend upon the obstetrician, nor upon the
nursing home where the patient is going to deliver
and there is little that the husband can do about it as
he has no control over the spermatozoon that
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fertilizes the ovum. However people indeed have a
wrong but strong belief in this respect. If two or three
daughters are delivered successively the blame is
put on the daughter-in-law as if it as if it is her fault
and she is tortured for the same for no fault of hers.
No one can predict which one among the millions of
spermataozoa will meet and cause impregnation.
We hear cases where the husbands has left wives
and the children and/or divorced the wife for the
same reason. People have changed the obstetrician
and the nursing home for the next confinement.
As stated elsewhere, conception, sex of the
baby, day and time of birth and even death, are
predetermined and are in the hands of Lord
Almighty: what all one can pray for is for a healthy
child physically and mentally either boy or girl.
Much research is going on trying to separate
the sperms with Y-chromosome and yet it is too
early to say anything regarding this. So also much is
in vogue these days regarding gene alternation and
designing of he babies including their sex, colour etc.
Pre-conceptional sex selection is condemned as an
example of positive eugenics that is an attempt to
improve (as defined by the Perpetrator) the inborn
qualities of the human race. Sex selection offers the
possibility of avoiding female infanticide and second
trimester abortions. While this seems attractive, the
conscientious opinion in our country and many argue
(which is more ethical and moral) that what is
needed is an elimination of inequality, not of baby
girls. Also a change in social values is required
which would result in an obstetrician offering
congratulations rather than commiserations on the
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birth of healthy female child.
Lay public consult astrologers who give hem
different kinds of advise regarding the month they
have to conceive or advise them to do certain pujas
or give them lockets etc for this purpose. Chinese
have a calendar prepared to advise the couple as
to when and in which month conception should occur
to predict the sex of a future child. None of these
help.
What unfortunately is happening today is that
by the chorion sampling or amniotic fluid
examination for chromosomal analysis or by
ultrasound examination the future sex of the baby
can be detected (but not determined!) and many
terminations of pregnancies are done if the foetus
inside is a female. Still worse, in some parts of our
country they make the mother kill the female baby
immediately afterbirth on the pretext of lot of dowry
has to be given at the time of marriage of the girl.
Mother killing the girl baby is like the fence eating
the produce of the land which it is supposed to
protect. What a sad state of affairs! While both the
above are unethical, on whom should one put the
blame - The husband, wife, obstetrician or indeed
society itself. Rightly the Government has framed
laws regarding the banning of the tests for sex
determination. Even so many are done. Even
otherwise, many a couple request for termination of
pregnancy when they already have two girl babies.
As written elsewhere the obstetricians are only
helping these women from falling into the hands of
quacks. Ultimately it is the society and the prevalent
social fabric which is responsible for our present day
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ills. So much is talked on T.V., press and
advertisements etc. about the protection of the girl
babies. However, in day to day life one sees exactly
the reverse happening. The people who exhort so
much and talk about are the same people who want
and demand lot of dowry from the parents of the girl
at the time of the marriage. And this is the root cause
of the evil.
For a male foetus to develop and survive and
preserve its sex, the quantity and quality of these
hormones testosterone and Mullerian-suppressing
hormone are essential. Male baby has to survive in
mothers womb surrounded by so many of the
female steroid hormones produced by the placenta.
If and when the testosterone is not produced or not
being utilised by the end organs because of enzyme
defect then only the sex differentiation into female
occurs or may occasionally lead to problems of
indeterminate sex. This is what Prof. Jeffcoate wrote
Woman is a woman not because she has ovaries.
She has ovaries because she is a woman or better
still she is not a man.
It is also seen from the above that both males
and females have in them the remnants of the
sexual apparatus of the other. In males the Mullerian
apparatus that ultimately leads to the development of
womb and female sexual genitalia are suppressed
by the testosterone and the Mullerian inhibiting
hormone. Whereas in women, the Wolffian duct and
other apparatus responsible for development of male
genitalia are suppressed. There is much to be aid
that femininity is neutral state and masculinity is
superimposed characteristic. A seen in daily life
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many men are effeminate and many women are
slightly masculine in bearing and outlook. A men
may be smooth skinned and fastidious about his
clothes and a woman may be slightly flat chested
and have hairy legs without being significant. These
are also reflected in their character, behaviour and
their outlook in life. In short, the borderline between
the two-male and female if not on the physical plane
but on the mental plane, is vague and impossible to
define. Even experiments have shown that castration
of male species in early life has lead to the
development of female person. Castration after birth
also (as in eunuchs) makes them behave like
females. Probably it is for this reason, in order to
safeguard the zanana or ladies in the palaces that
Kings used to keep eunuchs (after forcibly castrating
men) to guard them. Even today, this unethical
practice of castrating forcefully healthy males after
kidnapping them is done by the Hijras or eunuchs
themselves, behaving like a mafia, which is indeed
deplorable.
Female genital mutilation, misleadingly known
as female circumscision entails the total or partial
cutting away of the female external organs including
clitoris. This custom is prevalent in sub-Saharan
Africa, the Arab world and in some other Islamic
countries. Whatever be the reasons underlying this,
one feels sad to note that women who escape
mutilation are stigmatised and are not sought in
marriage, which helps to explain the paradox that the
victims of this practice are among the strongest
proponents (as in case of the eunuchs). It is the
ethical and moral duty of everyone, including
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organisations like the WHO to work together and
educate the people in effectively eliminating such
needless practices.
Transexualism is defined as a disturbance of
gender identity in which persons anatomically of one
sex have an intense and persistent desire for
medical, surgical and legal change of sex, so that
(Freedman et al 1976). In these people castration is
done first and a functioning vagina is then created
and female hormoses administered for the
development of breast etc. and they lead a sex life of
women. The only instance in our mythology we read
about change of sex is that of Sikandi. Here Amba a
princess prayed to the Lord so that she could be
born and brought up as a man in order to take
revenge against Bhisma Pitamaha, as he refused to
marry her because of the vow he took that he will
never get married. Bhisma also vowed that he will
not fight a lady in the form of a man. But we did not
read anything like males wanting to get their sex
changed to that of females. Whatever may be the
explanation, the desire or disturbance of gender
identity or orgenic imbalance in favour of females,
yet one cannot apprehend or appreciate such a
change. Is it ethical!! Probably this sort of desire is
due to the effect of Kaliyuga!
Hindu mythology believes that the Divine
aspect or power is only one. On the male side it is
represented as a Lord Brahma, Lord Vishnu and
Lord Maheshwara. On the female side, as Goddess
Saraswati, Goddess Laxmi and Goddess Parvati. It
is said the Lord Vishnu has Goddess Laxmi in his
chest (Vrakshoviharini manohra divya moortey) and
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Bhagwan Shiva appears as Ardhnariswara giving
half of this body to Goddess Parvati. It is shows that
ht Lord Purusha and Prakriti or Shakti or energy are
equal. Probably this is the highest form of philosophy
saying how the Bramhan can manifest and can be
worshipped.
And finally, whispering a word of wisdom again
in every bodies ears, not to be choosy in the sex of
the child to be born. Nature has created two different
sexes for continuation of the species. Why disturb
the balance of the nature!
ETHICAL ASPECTS OF INDUCED ABORTION
The old order changeth yielding place to new
Lord Tennyson.
There is no aspect of Obstetrics and
Gynaecology which has aroused more controversy
than the termination of pregnancy. It arouses
personal emotions, involves ethical considerations
and as such cannot be considered ion medical terms
alone. From the time of Hippocrates the consensus
of medical opinion was opposed to induced abortion.
Even as late as 1948 Dee Lee and greenhill in their
textbook Principles and practice of Obstetrics wrote,
One of the saddest commentaries on modern
civilization is the prevalence of criminal abortion. A
young physician will not be in practice very long
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before he is approached with a request in a hundred
open or concealed ways to perform criminal
abortion. All arguments are brought to bear;
friendship for a family, disgrace of a child born under
untoward circumstances, the impossibility of caring
for large number of children, ill health and eugenics.
The physician should not permit anyone of these
supposed factors to influence him to perform
abortion because:
(a) It is murder.
(b) It is a criminal offence punishable under law
(c) Performed in the way most of these
operations would have to be performed,
infection is most likely to follow and perhaps
death of the patient with a possible prison term
for the perpetrator.
(d) Accidents such as perforation of the uterus
and anaesthetic deaths are not uncommon.
(e) If the physician does it once he is a lost
man as the woman, no matter how firmly she is
bound to secrecy will tell her friends and soon
his reputation as an abortionist will be
established.
As such, abortion was done only as a
therapeutic procedure. Even here the moral and
religious aspects were considered and in life
threatening conditions induction of abortion was
done as conservating operation saving the
mother and not sacrificing the child!.
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This prevalent attitude in those days led many
young women to commit suicide. Haemorrhage and
infection after procurement of abortion by quacks,
unqualified persons, perforation of uterus and the
viscera, etc. were common. If delivered secretly
mother used to cause infanticide or left the baby in
some place. In more sophisticated people abdominal
hysterotomy was done in the name of appendicitis
operation. All these were of common occurrence
years back. Induced septic abortion was the highest
cause of maternal mortality. The most important
cause of death is due to gram negative organisms
aerobic or anaerobic or in some clostridium welchii
infection causing gas gangrene or clostridium
Tetanii, causing tetanus. Even today unfortunately in
abortions done illegally many women are lost as a
result of haemorrhage and infection or if alive suffer
from a legacy of complications.
Considering this aspect of high mortality due to
illegal septic abortion on the recommendation of a
committee appointed for this purpose, the Parliament
liberalized abortion laws and passed MTP Act in
1971 which came into force in April 1972. Abortion is
permitted one medical and socio-economic grounds
as listed below:
(a) The Act permits termination of pregnancy
by a registered practitioner where the length of
pregnancy does not exceed 12 weeks and by
two acting together where the length of
pregnancy is between 12-20 weeks of
gestation.
(b) Termination of pregnancy can be provided
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if the doctor is of the opinion:
(i) Continuation of a pregnancy would
pose a risk to the life of a pregnant
woman or cause injury to her physical or
mental health.
(ii) There is a substantial risk that if the
child was born it would suffer from
physical and mental abnormalities as to
be seriously handicapped.
(iii) The pregnancy is alleged by the
pregnant woman to have resulted
after rape.
(iv) The pregnancy occurred as a result
of failure of any contraceptive method
used by the woman or her husband for
the purpose of limiting the number
of children.
Further the Indian Law permits some
consideration of pregnant womans actual or
reasonably foreseeable environment.
Thus the law is quite liberal and is in
consonance with the health and demographic needs
of the nation. It is so liberal that under the law any
pregnancy can be terminated in the pretext of
anyone of the above regulations and raises
suspicions in the mind of the people that the Act can
lead to wholesale termination of pregnancy; i.e.,
destruction of human life (Bhroonhatya). In
Christianity especially amongst Catholics,
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termination of pregnancy is not permitted as in their
view life is life, either very early pregnancy or after
birth. In the Muslim world even a diagnostic
curettage in the latter part of the menstrual cycle is
not permitted unless pregnancy is excluded by
immunological test or by ultrasound. Even small
foetus expelled in a spontaneous abortion was given
traditional burial. But considering the number of
deaths due to illegal septic abortion especially of
healthy young women in the prime of life, any right
thinking person will surely feel that it is better that the
abortion is done legally instead of illegally by quacks.
The risk of dying from sepsis after illegal abortion is
considered to be as much as 50 times greater than
after legal abortion. Likewise, septic abortion is still
the most common obstetric cause amounting to
nearly a third of maternal deaths. Comparatively,
legal abortion is a safe surgical procedure with a low
death/case rate.
If the pregnancy occurs as a result of rape is
the woman at fault and to be condemned? If an
unmarried girl is ditched is she to suffer; or for that
matter the family has already have enough children
and cannot afford to have any more because of
poverty. Probably all these must have been
considered by the committee and subsequent
endorsement by the Parliament.
While any registered medical practitioner can
terminate pregnancy the burden most often falls
upon the shoulders of the obstetrician and
gynaecologist. While the act gives legal protection if
the procedure is done according the regulations
prescribed, the doctor I am sure will in his heart of
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heart have the lurking feeling that he is doing sin in
terminating many pregnancies. This feeling is bound
to occur as one sees in the departments of
Obstetrics and Gynaecology many terminations are
done day in and day out. As one being the Head of
Department of Obstetrics and Gynaecology it fell to
my lot not only to start the OPD MTP centre at BJ
Medical College and Sassoon Hospitals and also at
J Group of Hospitals, Bombay. I was also
instrumental for the training of the staff,
postgraduates and also Medical Officers from the
districts posted for the same. I did 2 or 3 Swamijis
whether what I was doing was right or wrong. I did
not get a convincing reply.
Anyway my conscience was clear. We followed
the orders of the Government as duty bound. Even
otherwise when the couple comes and requests for
MTP, to any doctor, the decision for the termination
was taken by the couple and the gynaecologist is
only completing the procedure. One should take it
that probably in such cases it was His will and the
gynaecologist is only a nimitramatra provided he
does so with all due care and precautions so that the
mother is not endangered. He will only be guilty if he
takes undue advantage of the situation especially in
termination of pregnancy in unmarried girls.
Unfortunately even today many seek the services of
illegal abortionists because of lack of awareness of
the abortion services available, lack of privacy and
impersonal atmosphere, reluctance of unmarried
women and widowed women to go to hospital for
MTP, and lack of financial resources on the part of
the rural population to reach hospital in urban areas
as it is seen that in only 1 in 10 primary health
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centres have facilities for MTP.
ICMR study shows that majority of the abortion
seekers belong to the middle income group
married and have one or two living children and are
educated. Unmarried teen-agers for form 5-6% of
the cases. Drugs taken for postponement of
menstruation or medicines prescribed for any
physical ailment of X-rays taken for the investigation
and diagnosis in all these the patients are
becoming very apprehensive regarding the safety of
the future child and seeking abortion services.
Number of patients coming for 2
nd
trimester for
termination is gradually coming down yet still they
constitute a sizeable number of cases. Majority are
unmarried, teen-agers or widows. Most of them are
from the rural areas. Ignorance of being pregnant or
inability to take decision regarding termination of
unwanted pregnancy appear to be the major factors
responsible for the delay. The risk to the mother is
10 times more than when the termination is done in
the first trimester with the same setting. While in
MTP in first trimester the mortality is considerably
lower than those associated with continuation of
pregnancy and delivery, data shows that legal
abortion is one of the safest surgical procedures and
both immediate and late complications following
MTP are low.
Hence what is more ethical today is how best to
make the procedure safe and prevent immediate and
late complications and to see that MTP emerges as
an important maternal health issue. With that in view,
the following should be observed:
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(a) MTP for unmarried girls should not be done
unless ABO and Rh grouping is done. Even as
little as 0.1 ml ccc of blood can cause
sensitization and mar her future chances of having a
child. Anti D-Gamma globulin should be given
to all Rh- Negative women as a prophylactic
measure.
(b) Always rule out Ectopic gestation by clinical
as well as (if necessary by Ultra Sound) before
termination. It is imperative that all
gynaecologists should train themselves in USS
technique to confirm that the pregnancy is in
the uterus. Patients especially unmarried girls
will be reluctant to go to radiologist or
ultrasonographers for this investigation.
(c) In married young patients never do MTP
unless in exceptional circumstances. The fact
that the lady is pregnant shows that both of
them are fertile and this should be impressed
upon. In spite of all care tubal block can occur after
the procedure and the couple may have to go
from pillar to post to conceive again.
(d) Though Menstrual Regulation without
anaesthesia is ideal for upto 6 Weeks of
pregnancy, chances of failure rate are high
especially if there is congenital malformation of
uterus etc. Waiting for 2 more weeks is ideal
and better to do suction evacuation. This
waiting does not increase the complication
rate.
(e) Suction evacuation is better than the
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conventional dialatation and curettage (or
evacuation). The latter is followed by more
bleeding, incomplete evacuation or if drastic
curettage is done can cause intra-uterine
synaecia later. Also vacuum aspiration may be
a safer method as fewer side effects and
greater efficiency than Prostaglandins for first
trimester termination. This may not apply to RU
486 and miniprostrone where high success
rate is reported without surgical intervention.
(f) While giving local paracervical block, be
careful not to inject into blood vessels. Adding
Buscopan or Epidosin and pitocin to the
anaesthetic solution helps in smooth dilatation
of cervix. Back up sedation is essential when
doing under local anaesthesia.
(g) Minimizing trauma to the cervix is an
essential aspect of suction evacuation.
Keeping Laminaria tent or isabgol tent four
hours before the procedure helps easy
dilatation of cervix. They are very good
adjuants contrary to the belief the, complication
rates like infection are often very les.
(h) Perforation of the uterus can occur with
ease even in expert hands No one should be
overconfident MTP operation should not be
taken lightly. Everything should be ready in the
theatre to deal properly and the condition dealt
with immediately.
(j) Second trimester terminations are more
hazardous complication rate is very high, the
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risk to the mother being as much as 10 times
higher than in early trimester.
(k) Select a procedure which is safe, does not
have any contraindications even in high risk
cases and which gives reasonably good and
quick results especially in nullipara in whom
surgical interference should be avoided.
(l) Extra amnhiotic procedures are easier and
safer than intra-amniotic procedures. Avoid
intra-amniotic injections of hypertonic glucose
or hypertonic saline. They have lost favour as
they cause infection, hypernatremia and
disseminated intravascular coagulation.
(m) The period of pregnancy between 12-14-
16 weeks is a grey area; difficult for suction
evacuation from below and may not respond to
drugs. Prior dilatation of cervix with laminaria
or isabgol tent may help.
(n) Most gynaecologists would limit the using
of vaginal termination first trimester. Some
advocate vaginal termination even in second
trimester. Because of the large size of the
foetus bony parts of the foetus may have to be
crushed before removal. There is no doubt
that many would feel that the procedure has
crossed the limits of what they consider to be
ethically acceptable.
(o) Until newer and safer methods of non
surgical termination of mid trimester pregnancy
become available, hysterotomy with tubectomy
might be an acceptable alternative for parous
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women requiring mid-trimester termination and
concurrent sterilization in the prevailing
conditions.
(p) It is easier to motivate women for
contraception at the time of MTP. As per an
ICMR Report, before MTP only 25% of
abortion seekers used some sort of
contraception. At time of MTP 25% accepted
tubectomy 29% IUD and 9% oral
contraceptives. Thus MTP has brought 2/3 of
abortion seekers into effective contraceptive
care. Do a lamaroscopic sterilization or mini
laparotomy with MTP. There is no increase in
mortality or morbidity. also tubectomy is very
useful in overcoming domestic problems of
parous women. Thus an unwanted
pregnancy might act as a first step towards
compulsory contraceptive use in future.
(q) Legal abortion should not be considered as
a population control method. It is mainly for
safeguarding maternal health. However the
positive association between the two may be
further strengthened when abortion services
are provided as apart of the integrated
maternal and child health and contraceptive
care.
Emotional Support
Unwanted pregnancy can be a cause of acute
emotional stress. Many of those who seek abortion
are young and unmarried. They very often do not
know that when they miss a period it could be
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pregnancy. Here comes one essential aspect of sex
education (they must be told that if they miss the
period after intercourse probably they may be
pregnant (see chapter on Sex Education). There is a
great danger and resentment because the young girl
has been abandoned by her boyfriend when the
pregnancy occurred. Discussion and emotional
support may help the young patient to come to terms
with her feelings. The young patient is afraid of
termination but even more afraid of telling her
parents.
Following termination of unwanted pregnancy
many women report a sense of relief that their
immediate problem is solved. Others report a feeling
of guilt and depression. Women having a MTP
because of foetal abnormality may have a grief
reaction. In both the above a sympathetic concern
and support helps to go a long way for the speedy
recovery of the patient.
In the end, patients should be cautioned
regarding the sequelae of repeated and frequent
terminations. Repeated terminations are not good;
cervical tears, cervical infection, increased incidence
of gynecological problems like menstrual
irregularities and secondary infections could occur
and could lead to blocked tubes and infertility. In
those who conceive, repeated abortions and
premature labour etc are long term sequelae.
I am always reminded of what may Prof MKK
Menon used to say regarding MTP : At one time
students in the examination were asked what are the
indications for termination of pregnancy. It should not
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happen now that the students be asked as to what
are the indications for continuation of pregnancy.
INFERTILITY
The desire for children by the normal woman is
stronger than self interest in beauty and figure,
stronger than the claims of a career. Childlessness is
generally a tragedy to the married woman and it can
be a cause of marital upset as well as personal
unhappiness and ill health. It may result from
recurrent abortion and still birth but the commonest
cause is failure to conceive. Sterility (infertility) is an
absolute state of inability to conceive.
-
Jeffcoate
Sterility was formerly regarded as a disgrace, as a
mark of divine displeasure, as a ground for
divorce or marital breakdown or even suicide (on
the part of woman only); in this she is goaded and
haunted by constantly being called barren and the
insinuations by every one in the family and
relatives. To propriate children, Sastras have
suggested various rituals like prayers, sacrifices
and the like. Awareness of male infertility is of
recent time and therefore man used to marry two
or more wives for the sake of children. When
childlessness affected the King or national heads
it had often changed the whole course of history
and it still does so even in everyday life in
families. Unfortunately the sorrow of childlessness
is kept by the couple to themselves. Only now a
days, with the dissemination of knowledge, an
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altered outlook and the availability of various
tests, advice and treatment, infertility is freely
admitted and therefore appears common.
Fertility and sterility: Fertility is a relative rather
than absolute state. If a couple gets married and
conception occurs, they are considered as fertile.
However majority of people fall into the category
of neither fully fertile nor sterile. In such cases low
fertility in one can be balanced by high fertility in
the other and the fertility of a marriage is the sum
of the fertilities of the two partners. But if both the
partners are low in fertility then sterility occurs.
Fertility varies from time to time in the same
individual. At one time it was thought that except
in childhood males are fertile throughout life time
even in old age. Of late because of stress of
modern day to day life, smoking, worries etc sub-
fertility is commonly observed in men.
Physiological sterility or sub-fertility is usually low
till age of 16-18 years (even though
menstruation is occurring regularly) probably
because the menstrual cycles are anovulatory.
Maturation of genitalia is also a prerequisite
before they become fully functional. They explain
why in rare cases fortunately conception does not
occur in case of rape or abuse. Low fertility during
pregnancy and lactation give women some
reprieve. Fertility again falls after the age of 40
due to infrequent ovulation.
Familial disposition: Genetic constitutional
factor; no explanation can be given as to why
some families have a high and others a low
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conception rate. Some families have only one
child. If that person grows and gets married, the
couple has a sixty percent chance of pregnancy;
even if it occurs, they have only one child. Sub-
fertility is often observed in obese, heavy build
and women with masculine traits and this
underlines a constitutional abnormality. Height
and weight are not direct causes of childlessness
nor athletic prowess and pursuits lower fertility.
Occupation and Environment: Fertility is high in
country dwellers rather than town or city dwellers.
It is also high among people who live by manual
labour than in those whose work depends upon
mental activity. Though statistics show that fertility
does not vary with social class yet it is a
common observation that higher the social class,
less the number of children. It is due to late
marriages in higher class or voluntary sterility
one marriages in higher class or voluntary sterility
one cannot say. Diet plays no part in fertility
unless it is so deficient as to interfere with ovarian
function.
Anxiety and Apprehension: Nervous
temperament and extreme anxiety leads to lower
fertility. Tension can lower fertility through the
action of hypothalamus or by causing spasm at
uterotubal junction. It is often stated that when a
couple adopt a baby they tension is relieved
and they are likely to have one of their own
afterwards.
Contraception: Usually does not lower fertility
unless it is practiced for a long time and the
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method not a commonly harmful one.
Postponement or delay of childbearing does
however mean that time is passing on and the
age factor is operating.
Incompatibility: It was observed that some
couples failed to reproduce but when they
separate and marry someone else they have
children. Though incompatibility as such is not
demonstrated but possible immunological
reaction of a woman to a particular semen can be
present as evidenced by presence of sperm
agglutinins in circulation.
When to investigate a case of Infertility
A highly fertile couple take an average 6-7
months to achieve pregnancy and 80% (4 out of
5) conceive within one year of marriage and 95%
after 2 years. In younger age group failure to
conceive during 2 years of adequate opportunity
is acceptable for justifying full investigation. For
others a period of twelve months is justifiable
especially if the woman is in her late twenties or in
her thirties.
Ethically, should investigations be done in a
case where one or both partners are HIV
positive? The conscientious opinion is Infertile
HIV infected patients need and should be given
careful counselling, within the limits of current
knowledge, about the infectivity, pregnancy,
breastfeeding, parental illnesses likely to occur
during pregnancy including danger to life before
one embarks on initial investigations.
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It is advisable to follow the guidelines given
below in handling cases of infertility.
(a) Unless the couple is very young, all married
couples should be advised dont delay the
first if they conceive it means they are a
fertile couple and every one in the household
will be happy.
(b) Never prescribe O.C.s (oral
contraceptives) for a long time postpone
pregnancy. If they do not conceive they blame
the pill and the doctor for not conceiving
though there may be other factors responsible
for infertility.
(c) If the periods are irregular and scanty from
puberty all the more reason not to prescribe
O.C.s for contraception. They can cause post-
pill amenorrhoea. These people should be
encouraged to conceive as early as possible.
(d) Reassurance may be all that is necessary
when couples complain of infertility too soon. A
simple explanation of the physiology of
conception and that ovulation occurs between
8-18 days in a 28 day cycle so that the
couple follows natural inclination.
(e) Remove the following misconceptions:
(i) Many women have a wrong notion that
unless they experience orgasm they
will not conceive. If it were so, pregnancy
should not result after rape. Orgasm may
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however eliminate tubal spasm, stimulate
cervical activity and encourage secretion
which are favourable for the upward
migration of spermatozoa and encourage
conception.
(ii) After coitus most semen escapes
from the vagina and patients often think it
to be the reason for sterility.
Floursemenis is normal and never a
cause of infertility. There is always
enough semen left to fertilize. Yet to
reassure advice her to lie down for 10
minutes or more after intercourse with a
pillow under her buttocks, so that the
semen is in contact with the cervix.
(iii) Overwork, anxiety, stress and strain
of life and in addition smoking and heavy
drinking, exposure to sexually
transmitted diseases as also to some
toxic agents in the workplace all these
affect fertility. Attention to these must be
given. A long care-free holiday may
sometimes be the remedy.
(f) There is a wrong impression that if the
couple live separate for a few months and later
their reunion will be fruitful. If the cause of
infertility is immunological then the levels of
sperm agglutinins in the wife will fall and she
may conceive. Otherwise this brings no more
pregnancies than uninterrupted married life.
(g) Coital problems are probably related in 3-
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4% of cases. AT one extreme it may be
impotence in male, or, due to premature
ejaculation or vaginismus and severe
dyspareunia in female that coitus occurs
rarely. If one is to assume that normal ovum
can be fertilized in terms of fertility is upto 72
hours in the fallopian tube coital frequency of
less than 3 times a week may in its own right
contribute to difficulty in conception.
(h) There is an increasing pressure to
investigate and treat infertility and the pressure
may lead to unnecessary and repetitive
investigations.
(j) It is ethical to investigate the husband first.
Years before, the wife was always sent for
investigation. Many husbands used to refuse
getting semen examined. They equate
satisfactory intercourse with fertility. Much to
everyones dismay they used to find that the
cause lies in them for infertility.
(k) It is sad to see patients going from pillar to
post. Investigations like laparoscopy, hystero-
salpingo-gram, endometrial biopsy and
hormonal investigations repeated over and
over again and seeing the patient waiting in
the queue with a full bladder at ultrasound
clinic for ovulation studies. It is always better to
complete all investigations in a short time-
rather than a protracted time taken for the
same. (Non-invasive procedure like trans-
vaginal sonography are gradually replacing
laparoscopy in the diagnosis and treatment of
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infertility cases).
(l) Patient should be advised not to abandon
treatment especially if clomiphene is given for
induction of ovulation. If conception does not
occur after three months it should not be taken
as a failure. Treatment should be extended for
some more time with or without other drugs.
Surprisingly in some cases conception occurs
after stoppage of treatment.
(m) In the end, optimism should be the keynote
even when investigations suggest that the
prospects for pregnancy are poor.
(n) Even if both husband and the wife after
investigations were found normal in every
respect and there is no absolute cause, yet in
some, conception does not occur such are
called cases of unexplained infertility and are
a monument to medical ignorance and a cause
for concern. In the absence of a determined
cause, there is a logical sequence i.e no
treatment. In spite of IVF and embryo transfer,
some do not conceive, which only shows that
unless Lord Almighty blesses whatever one
may do, success will not occur.
End Results of Treatment
(a) Whatever treatment or advice is given to an
infertile couple conception will not occur in
certain cases this is inevitable by the laws of
chance that govern conception.
(b) It is all too easy to claim a coincidence as a
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dramatic cure. Gynaecologist should only do
his part in the treatment to the best of his
ability and judgment and leave it it is for the
Lord to decide.
(c) Gynaecologist should not feel humbled to
refer the patient to an institute where
sophisiticated procedures like microsurgery,
endoscopic surgery or IVF and ET are done if
the patient requires and can afford the
treatment. (However it is only ethical in all
these procedures that one has to take into
consideration technological limits, financial
resources and complication rate. Likewise, IVF
and ET should be conducted in such centres
where everyone is well trained and devoted
solely for this purpose).
(d) The occurrence of pregnancy after a
treatment does not mean that fertility is raised.
(e) Two thirds of the couples who produce one
pregnancy after a phase of infertility find it
impossible to repeat the performance. (Only in
those cases of unexplained infertility that after
a gap of a very long time the patient can
conceive two or three children). It is therefore
unwise to claim a cure for any form of
treatment of sterility.
(f) While treating the patient should not be
made to concentrate on the problems of
infertility; otherwise the complaint of infertility
becomes an obsession and causes profound
unhappiness and may even lead to
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estrangement of partner in marriage.
(g) It is for this reason, treatment should never
be unduly protracted and complicated.
Treatment should be as rational as possible
and if not successful within a reasonable
period should be abandoned and the couple
referred to other sophisticated centres.
(h) All the same there is always an optimum
time to call a halt and a desperate woman
requires protection from those whose
enthusiasm clouds their sense of proportion
and their scientific outlook.
(j) When at last pregnancy occurs to a woman
who has waited too long it carries with it
certain risks like ectopic gestation, abortion
and PIH (Pregnancy Induced Hypertension),
and high incidence of foetal malformations.
Hence its management demands almost
rigorous attention.
Ultimately it is the Divinity that decides even
the fruits of fertility.
AID ADOPTION : ETHICAL
CONSIDERATIONS
If in the course of investigations an
irremediable barrier for fertilization is found in the
husband, the gynaecologist should explain the
hapless predicament to the barren couple and in
a sympathetic way, guide the couple to adjust
their married philosophy to that of a childless
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union. There are of course two alternatives
neither of which should be suggested by the
gynaecologist. They may decide to adopt a child
or have the wife to submit to heterologous
artificial insemination (AID).
Donor insemination may be suggested by
the sterile couple who argue that it is better that
they should have a child which is Half theirs than
adopt one which neither has any personal or any
genetic link. Usually the woman is guided by her
powerful maternal instincts, while the man feels
very responsible for his wifes unhappiness and
truly suppresses any personal objections to the
idea. Often it is the husband who is more insistent
on insemination. Arguments and persuasions of
this kind are inevitable and the following should
be considered by the physician before embarking
in the procedure:
1. Thought he procedure is widely termed
semiadoption and therapeutic insemination -
yet he procedure is considered socially
unorthodox, genetically tricky and morally
unacceptable by many.
2. Legally the procedure is equivocal. O
statutory requirements for the procedure exists in
as much as the law has not formally accepted the
inevitability and desirability of semi adoption. But
on the other hand there is no law that specifically
forbids the practice. Also it is not clear regarding
the legal status of the child and thus it may
jeopardize the emotional adjustments of the child.
Even if the physician obtains the written consent
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of the couple yet it may not satisfy all the
questions likely to be raised in the court room.
Prerequisites for Heterologous Insemination
(a) Male partner must be azoospermic,
serverely oligospermic, necrospermic or has a
transmissible hereditrary diseases.
(b) Doctor must evaluate the marital situation,
carefully as AID cannot be used by the sterile
couple merely as an adhesive agent to glue
together a cracked marriage.
(c) He must insist on a waiting period for the
couple to think thighs over and make sure
that the couple are mature and well adjusted in
a stable marriage.
(d) No AID should be done without the
husbands consent in writing. If done it may
merely amount to an act of adultery and will be
accepted as grounds for divorce.
(e) Donor should be healthy, mature male of
proven fertility, with a favourable hereditary
background and without clinical or laboratory
evidence of gonorrhoea, syphilis, AIDS and
any transmissible disease.
(f) The donors intelligence should match with
that of the parent and he should be of similar
physical proportions to the husband.
(g) For social and phychological reasons the
donor be unknown to the barren couple and all
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steps be taken to preserve his anonymity. Also
the procedure must be kept secret.
(h) The wife must be known to be potentially
fertile and the time of insemination must
coincide with that of her ovulation.
The reaction of the couple after the birth of a
child resulting from AID cannot be foretold by
themselves or by their medical attendant. Even
though before the procedure the man is the one
to insist, yet it is the an act of self effacement on
the part of the man whose pride had been
wounded by the discovery that he is the sole
cause of the fruitless union. These sentiments are
not enduring and they disappear. Afterwards the
man is likely to be jealous even though he may
hide it. Moreover during a marital tiff one or other
partner may sooner or later use conception
circumstances to hurt the other; and there after it
can never be forgiven. A child born by AID rarely
succeeds in saving a marriage which is
floundering and the child then suffers.
As written above no statute or law exists to
clarify the status of children covered by AID:
(a) Can the child be registered in the name of
husband?
(b) Are they legitimate or illegitimate as AID
offspring are not children of mothers partner?
(c) Should the child be told about his/her origin?
Otherwise the whole family life will be based on a
lie. But many couple wont agree with this.
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(d) In a marriage breakup the wife may deny the
ex-husbands access tot the child on the ground
that the child is not his. Or the husband latter
could refuse to pay maintenance for the same
reason.
(e) Also of concern is the inheritance, should the
husband die intestate.
(f) What is the relationship of the donor and the
offspring? Can they seek access to the offspring
they fathered or a legislation should be enacted to
remove any rights or responsibility of donors.
(g) Equally important ethical problem is can an
AID be done on a woman who has no partner, yet
she wants a baby all the same.
All the above are unanswered questions. Hence
many advocate against performing AID even if done
in good faith in the interest of the couple because
of ethical, religious and legal objections.
Yet in the developed countries, in many states
laws are being enacted to remove the legal
impediments. With the new technique of cryo-
preservation of sperms, and establishments of
sperm banks many infertile couples are treated with
AID. Even preservation of ova or sperm by freezing
can present problems with the gynaecologist. Any
damage to the tissue in the freezing process may
constitute negligence. However there are more than
quarter million donor children in USA, alone and an
additional one lakh in the rest of the world.
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ADOPTION
Individual outlooks differ regarding adoption of
a child. Some couple find the idea attractive and
others cannot tolerate it. Only the former make good
foster parents, even though the venture may not
always bring the happiness expected. Hence
adoption as a solution to the sterility problem
deserves cautious approach and initiative should
come from the infertile couples and not from the
gynaecologist. Pros and cons should be discussed
regarding for or against the procedure and the
couple must also be made to realize that they may
later on have a child of their own especially in a
cases of unexplained infertility or even in cases of
idiopathic oligospermia. It is surprising, while wanting
to adopt many a couple prefer a female child
instated of male. This is exactly opposite to their
expectation after a normal delivery. Is it because
they feel that the female babies look after their
parents well in their old age? There is an old saying,
son is a son till he gets married and a daughter is a
daughter forever.
Insemination with mixed semen (AIHD)
In order to quieten conscience of the couple
and to provide hope, mixing of the husband semen
with that of donors semen is suggested. If the
woman conceives the origin of the fertilizing
spermatozoa then remain in doubt. If the husband is
not sterile this procedure is not justified and if he is,
the method has all the objections of AID.
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WHAT DO OUR SHASTRAS SAY
REGARDING AID?
It is interesting to know the view prevalent in
our Puranas and scriptures. It was a regular
accepted procedure to call some male to fertilize the
woman in case the man was impotent and this is
called Niyoga. This applied even to kings. In
Mahabharata King Santanus wife Satyavati
requested Vedavyasa to impregnate Amba, Ambika
and Ambalika, when their husbands died without
leaving any progeny. That was how Dhrutarashtra
and Panduraja were born. Unfortunately Panduraja
was cursed by a Rishi couple (when he mistakenly
killed them) that he would die the moment he tries to
enjoy with his wives Kunti and Madri. Pandu told
Kunti to have children from whomsoever she
desired. Kunti was given five boons (varas) by
Rishi Durvasa Mahamuni when she served the
Rishi before her marriage. In her ignorance Kunti
wanted to test the boons or varas. She thought of
Bhagwan Surya and when the Lord really came she
was stunned. Karma was born then. It was written by
Vedavyasa in Mahabharata that Karna was born not
of consummation of marriage but by
Parthenogenesis or self fertilization. It is the solar
energy that was responsible. In the same way, after
marriage, when Pandu told Kunti to have children
from someone else, she refused. Keeping in mind
the boons she prayed to Yama Dharma Raja; i.e.
lord of Death. He typifies the energy which hold the
universe and is protector of Dharma like Lord
Brahma. That was how Dharmaraja was born. Kunti
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then prayed to Lord Vayu Deva the energy which is
blowing and present everywhere just like
electromagnetic waves and Bhima was born. Arjuna
was born from the blessings of Lord Indra who
represents the Atman. Lord said He is Indra among
all devatas. Then Kunti requested Ashwini
Devatas to bless Princess Madri. Ashwini Devatas
are twins who represent energy one as a positive
charge and other as a negative charge, without
which current cannot pass through. By the blessings
these Devatasi Madri gave birth to Nakula and
Sahadeva. It must be emphasied again that Pandavs
as well as Karna were Varaputras and also born by
parthenogenesis. In his sankalpa to be born again
and again whenever there is a deterioration of
Dharma Lord Almighty takes birth on the earth, as
He has promisedSambhavami Yuge Yuge. He
had taken the birth of Lord Jesus again through
Parthenogenesis. So Kunti, Madri and Virgin Mary
are all incarnations of purity and virtue.
Present status of AID in our country
AID acquires an entirely new dimension in our
country in view of the threat posed by sexually
transmitted disease (STDs) and especially the
dreaded AIDS (Acquired Immuno Deficiency
Syndrome). It comes as a rude shock to anyone
regarding the unethical and immoral ways AID is
practised:
(a) In several parts of our country AID is
practised by fake babas, hakims, sex
specialists and quacks. In the name of putting
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vibhuti or sacred ash and also doing some
rituals, many infertile women from rural areas
and uneducated class are being exploited and
fall a prey to their unethical ways. It could
mean the end of their normal healthy life more
so because of the threat of contacting
infections which looms large over an ignorant
populace.
(b) Even in medically assisted conception (with
the use of sperm from third party) where
women bring semen from outside for
insemination with mutual consent; it is
shocking to note that in some places quacks
and pathologists are providing them with
unhealthy poor quality semen and naturally
poor genetic material.
(c) The situation has become so deplorable
that in some places semen is collected from
those very people who are professional blood
donors. Most of them are drug addicts, STD
carriers, sick slum dwellers in the cities and
these essentially belong to working labour
class, beggars and vendors. In short
professional blood donors, have now become
semen donors. Who so ever
pathologist/gynaecologist is either selling or
inseminating semen from such people is
virtually, selling sexually transmitted diseases
and indirectly spreading AIDS, thus rendering
them infertile for life. These women have no
chance to live atleast a decent life even at the
cost of staying without having offspring.
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(d) It is now mandatory that semen should be
tested for HIV and if found to be negative,
semen should be frozen and quarantined for a
period of three months; i.e. window period
and tested again for HIV before it is considered
fit to be used in a recipient even if the
specimen is from good healthy and well
educated donor. Sadly this practice of freezing
and retesting the sperm after three months
window period is not followed in all sincerely
even in well established laboratories.
(e) Unfortunately it is found that it is the woman
who gives in and arranges to have her being
inseminated for fear of being rejected by her
spouse and his family not realizing the
consequences that such a procedure could
mar all her chances of a future pregnancy and
it could be a source of worry rather than joy.
(f) According to a recent estimate as many as
600 people could be getting artificially
inseminated in National Capital alone in a
month. One can imagine what would be the
problem on a national level.
(g) It is a dismal truth that no proper guidelines
have been issued by the government for
setting up sperm banks, buying and selling
semen for reproductive purposes. There is a
great need to establish such banks which
would provide healthy and rich genetic
material.
(h) Unless the steps are taken to contain the
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menace at the beginning that is right now, the
casualties will be surmounting and no one will
be able to stop the HIV epidemic from
engulfing the country.
Rightly it is said, Prevention is better than cure
- so be the watch word.
ETHICAL PROBLEMS OF IVF & SURROGATE
MOTHER
The problem of infertility has now entered the
mainstream of medicine and the treatment of
infertility involves the gynaecologist, infertile couple
and those which involves a third party as donor of
egg or sperm or embryo or as a surrogate mother. In
short the concept Artificial family is becoming
increasingly familiar and widely discussed.
IVF In-vitro fertilization and embryo transfer
Ethical objections to the use of IVF treatment arise
because of the fear of fertilizing the egg and the
sperm in the laboratory or it is extensively expensive
given comparatively few people who benefit from it
and as it involves certain health risks; also whether
super ovulation is necessary to the success of the
IVF; what is the optimum number of embryos to be
inserted in the uterus with the best hope of
successful implantation and what is the risk of the
occurrence of multiple births. In the bargain there is
also a risk to the gynaecologist i.e. handling the
ovum of embryo may lead to deformity or a genetic
muddle can occur and the consequent negligent
claim.
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IVF today is used in cases of blocked tubes,
unexplained infertility and mild endometriosis.
Analysis of data in world literature has shown that
IVF has not proved to increase the likelihood of
pregnancy over no treatment, except where
Fallopian tubes are blocked. Also unfortunately,
some clinics are recommending IVF to couples after
a very short duration of marriage, without due trial for
natural methods.
Other ethical objection is regarding the embryo
(zyote) research which is done with a view to
improve the success of IVF procedures. The
research includes observing fertilization and early
development of zygote under different conditions
and using different culture media while at the same
time zygotes are treated with respect. This pertains
to the left over embryos in the IVF and the embryo
transfer. Some people argue that the embryo after
fertilization is a human person and must be
guaranteed full protection of the laws and not used
for research even with parental permission.
However, one has to make a distinction between 4
cell or 8 cell or 16 cell embryo and a fully developed
child and they should not be equated.
Gynaecologist who is professionally committed to
caring for women should convince and change the
moral feelings of the people that if research is in
jeopardy, all kinds of desirable improvements in the
field of infertility will be at risk; and by the powers of
persuasion should allay some of the ignorant and
alarmist fears.
Surrogate mother (proxy motherhood and
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womb leasing) : In the case of surrogacy using IVF,
the child is genetically the child of commissioning
people. The surrogate is simply acting as a living
incubator, and hence ethical problems are confined
to those relating to the surrogate. At the centre of the
ethical question is the question whether it is right to
use one person as a means to the ends of another,
however estimable these ends may be~. Does it
amount to exploitation of the surrogate even if she
has expressed her willingness? Is she not being put
to risk of pregnancy and child birth. If the surrogate
is being paid, is she not being used for Service
Undertaking? Has the surrogate sold her body or
sold her own child (son or daughter) even though
she entered willingly thinking that it will produce
nothing but good.
One the other hand if the surrogate offers her
service willingly enjoys being pregnant and is in
good health, psychologically tough enough to
withstand pregnancy and labour and hands over the
baby she has given birth to the commissioning
people, who have been desperate perhaps for years
to have a child which they will now have in some
sense the surrogate brings in lot of happiness in
the life of the couple.
There are other questions that may arise. Can
couples who are not infertile make use of surrogacy
or AID? Probably when there is evidence of some
malfunction or when the risk of passing on an
inheritable disease is so great then only IVF or
production of an artificial family should be attempted.
Should the surrogacy be kept as a secret from
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the public and the child that is born and lastly upto
what age can a surrogate mother be treated with IVF
(lot of controversies being discussed nowadays
when a 59year old lady surrogate mother gave birth
to twins and a 63 year old woman became pregnant
after being inserted with the egg taken from a young
woman). Can the surrogate mother refuse to hand
over the child and make it a ward of court. Problem
of consent may arise if the surrogate mother requires
an abortion: whose consent is necessary? To the
gynaecologist the patient must come first. But should
he take the consent of the biological parents for the
destruction of the child.
These are thorny, difficult and controversial
problems. All these point out that a gynaecologist
who recommends surrogacy has a tremendously
difficult decision to make and he/she has moral
responsibility for four persons infertile couple,
surrogate and the resulting child.
Fortunately in our country it will be quite some
years hence that the ethical problems of surrogacy
will arise.
IVF Was Known and Practised in Ancient Times
IN the Mahabharata, Gandhari, wife of King
Dhritarashtra, conceived but the pregnancy
prolonged for nearly two years; then she delivered a
mass (?Mole). Bhagwan Vyasa found that there
were 101 cells which were normal in the mass.
These cells were put in a nutrient medium and were
grown in vitro to full term. Of these, 100 developed
into male children (Duryodhana, Duhshasana and
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the other Kauravas) and one as a female child
(Dussala).
There are other well quoted examples which
refer to not only IVF but that a male can produce a
child without the help of a female. Saga Gautama
produced two children from his own semen a son
Kripa and a daughter Kripi, who were both test tube
babies. Likewise, Sage Bharadwaj produced Drona,
later to be the teacher of the Pandavas and
Kauravas. The story relating to the birth of
Drishtadyumna and Draupadi is even more
interesting and reflects the super natural powers of
the Great Rishis King Draupada had enmity with
Dronacharya and desired to have a son strong
enough to kill Drona. He was given a medicine by a
rishi and after collecting his semen, processed it and
suggested that AIH should be done for his wife, who
however refused. The Rishi then put the semen in a
yajnyakunda from which Dhrishtadyumna and
Draupadi were born. While the above are quoted as
examples of IVF and parthenogenesis, there is
another story which refers to embryo transfer. This
was regarding the seventh pregnancy of Devaki, by
the will of the Lord, the embryo was transferred to
the womb of Rohini, the first wife of Vasudev, to
prevent the baby being killed by Kansa.
HORMONES IN NORMAL AND PATHOLOGICAL
CONDITIONS
The female hormones oestrogen and
progesterone and the male hormone testosterone
though produced from different organs are all
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synthesised from the blood cholesterol. All have a
common chemical ring. Depending upon the number
of carbon atoms, testosterone 19 and oestrogen 18
carbon atoms. The synthesis of these hormones is
done by simple but different enzymatic processes. In
the synthesis of oestrogens, progesterone or
pregnanelone are produced as an intermediate step
and either they are converted to oestrogen directly or
at time male hormone androstenedione is produced
and then converted to oestrogen. This shows that
these hormones are very much inter-related. Either
by removal of hydrogen atom or by hydroxylation
etc. by the enzymes, one or the other hormones is
produced. Also in the testosterone if one carbon
atom is removed at 19
th
position, it is called 19-
nortestosterone. But the action will be that of
progesterone. If there is any fault in steroidogenesis
e.g. aromatization in the production of oestrogen,
more of androgenic hormone is also produced.
Another factor which governs the production of
hormones by the endocrines is what is called
feedback phenomenon. At the beginning of
menstrual cycle the steroid hormones are low.
FSH follicle stimulating hormone produced by
the pictuatary acts upon the ovarian follicles and
makes them produce oestrogen. Oestrogen in turn
inhibits FSH production, promotes LH (Leutinizing
Hormone) secretion which causes ovulation and
corpus luteum formation. Progresterone, which is
produced by the corpus luteum formation.
Progesterone, which is produced by the corpus
luteum inhibits the further production of LH. In the
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absence of conception both hormones oestrogen
and progesterone are withdrawn and this results in
changes in the endometrium ultimately leading to
menstruation.
Menstruation is the end product of a chain of
reactions starting from hypothalamus in the brain
acting upon the anterior pituitary which produces two
hormones FSH and LH and these in turn act on
gonads; i.e. ovaries which produces oestrogen and
progesterone acting upon uterine endometrium. If
there is a break in this hypothalamic pituitary
gonadal uterine axis either the menstruation does
not occur producing a condition called amenorrhoea
(suppression of menstruation) or the periods may
become very profuse menorrhagia or they become
irregular and produce a condition called
dysfunctional bleeding.
Menstruation is usually preceded by ovulation
and corpus luteum formation. For some unknown
reasons this does not occur and anovulatory
menstrual cycles occur. Anovulatory cycles are
common in adolescence and before the menopause
and the bleeding is excessive and prolonged.
Anovulatory cycles, if they occur during the child
bearing period cause infertility.
It should be noted that oestrogenes are called
hormones of the female. The growth and
development of the female genital tract depends
upon the oestrogens. The feminity, the contours,
texture of the female skin and hair and the shape of
the female form and the development of the breasts
are all due to oestrogens.
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The growth and vascularity of the uterus and
various physiological changes in pregnancy are due
to oestrogenes. By their controlling effect on blood
cholesterol oestrogens protect women during
reproductive period from myocardial infarction. While
it is so yet when the oestrogen production is not
counter-checked, ovulation and corpus luteum
formation and progesterone production do not occur.
This leads to hyperoestrinism producing anovulation
and infertility, Stein-Leventhal syndrome or
polycystic ovaries on one side and endometrial
hyperplasia producing abnormal and profuse
bleeding called dysfunctional uterine bleeding can
occur at any age-puberty, child bearing period and
premenopausal years. While reversal of the
condition with resumption of ovulation and
spontaneous cure occurs at time of puberty, and
treatment with drugs to induce ovulation and
occurrence of pregnancy cures the condition in child
bearing period, only complete cessation of ovarian
function through a spontaneous or induced
menopause cures the condition at the
premenopausal years. In extreme cases
hyperoestrinism can produce adenomatous
hyperplasia and later atypical leading to occurrence
of the carcinoma of the endometrium and ultimately
leading to occurrence of the carcinoma of the
endometrium. Also if the oestrogens are taken
continuously as in hormone replacement therapy for
menopausal symptoms, carcinoma of the
endometrium can occur.
This only shows that persons who are normally
good and do lot of good for others for some
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unknown reasons can change especially when
power comes to them and when cannot be checked,
Cause a number of problems. This only implies that
one should work within the limits prescribed but
when once they cross the physiological limits, they
can become erratic in functioning and behave
pathologically.
Other hormones are also associated with hypo-
or hyper-clinical state. But oestrogens differ from
others in that they produce and are responsible for
so many varieties of clinical conditions anovulation,
DUB, fibroids, endometriosis and carcinoma of the
endometrium and even carcinoma of the breast.
AMENORRHOEA
Amenorrhoea means without menstruation or
absence of menstruation. It is physiological before
puberty and periods of amenorrhoea lasting for 2-12
months during the first 1-2 years after menarche are
common in 50% of girls without any effect on their
fertility. Pregnancy is the commonest cause of
secondary amenorrhoea and suppression of
menstruation is the leading symptom of early
pregnancy. Menstruation is usually suppressed for
varying periods after abortion and labour but
especially by lactation when the hypothalamic-
pituitary system concentrates on the production of
prolactin rather than gonadotropins. Menopause
comes about when the ovaries, with all their Graffian
follicles disappear and fail to react to the
gonadotrophic stimulus.
Pathological amenorrhoea : Amenorrhoea is a
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symptom and not a disease. It is divided into 2
groups primary when periods are not established
by 16-17 years and secondary when a patient had
periods before and subsequently the periods have
stopped.
Primary amenorrhoea most often is caused by
gross errors in the development of uterus and
ovaries as following:
(a) Congenital absence or gross hypoplasia of
the uterus a pitiable condition where the
growth, height and weight of the patient are
good, looks entirely feminine with good
development of a breasts etc and for no faults
of hers the uterus is not developed.
(b) Congenital aplasia of the ovaries Turners
syndrome due to chromosomal anomaly.
These patients have only 45 chromosomes
(instead of 46) including XO sex chromosome.
In many cases mother nature causes death of
the fertilized ovum leading to abortion. Those
unfortunate who fail to abort and continue to
term and deliver, later in life present with this
syndrome which has the following features
webneck, gross carrying angle of the forearms,
no development of secondary sex characters
and present with amenorrhoea.
(c) Congenital obstructive defects in the genital
tract especially non-canalization of the vagina
called atresia of the vagina and often
associated with absence of the uterus.
(d) Other causes include intersexual disorder
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like testicular feminization syndrome,
hypopituatary dwarfism and hypothyroid
dwarfism.
In all the above nothing can be done and
the patient has to reconcile to her fate; except
in 3 conditions:
(i) Atresia of the vagina : where a
functioning vagina can be made for
sexual purpose but the patient cannot
conceive though she can have a very
happy sexual life.
(ii) Imperforate hymen causing
cryptomenorrhoea or concealed
menstruation but the patient presents
with amenorrhoea.
(iii) Testicular feminization, where the
end organs are insensitive to the male
hormones and hence signs of
feminization occur.
From clinical and a ethical point of view it is the
duty of every gynaecologist to insist and do a pelvic
examination and ultrasound scanning in girls past 16
or 17 years presenting with a symptom of primary
amenorrhoea. Then only one can diagnose atresia of
the vagina or testicular feminization syndrome.
Secondly, to advise the parents not to get the girl
married without letting the other party know about
her condition as in many cases this leads to the
break-up of the marriage. A functioning vagina
should be created only a few months before the
marriage with the clear understanding on both the
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sides that she will not have menstruation and that
she cannot conceive but can have a very happy
sexual life.
PATHOLOGICAL AMENORRHOEA
The causes of Pathological Amenorrhoea are
legion and varied; and they reflect what we observe
in every day life.
(a) Too much or too little or faulty production is
not good. In primary ovarian failure, too little of
hormones are produced; in premature ovary
failure ovarian follicles get exhausted and
hence no hormone production occurs. Too
much production of oestrogen as in
metropathia, functioning tumors of ovary or
excessive production of progesterone by
corpus luteum cysts produce amenorrhoea.
Enzyme defects causing abnormal or faulty
steroidogenesis produces the syndrome of
polycystic ovaries.
(b) Under-nutrition or over-eating are both bad
for health; severe anaemia and malnutrition on
one side, obesity and diabetes on the other
side, produce secondary amenorrhoea.
Slimming is good but enforced slimming to
keep up the figure is not good as in anorexia
nervosa. Tuberculosis (Kshaya Roga)
gradually lessens the body resistance and
completely destroys the endometrium as well
as the tubes of the uterus.
(c) Breast feeding is good both for mother and
the baby. But agin in prolonged lactation the
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hormones are suppressed leading to a
syndrome of amenorrhoea galactorrhoea
called Chairi-Frommel syndrome. In a similar
way oral contraceptives taken for a long time
inhibit the hormone synthesis causing
amenorrhoea.
(d) Co-ordination is the keynote for successful
accomplishment of any work. A positive
response is essential. In resistant ovarian
syndrome, ovaries do not respond to
gonadotropins from pituitary and endometrium
can be refractory to the steroid hormones and
the end result is amenorrhoea.
(e) Stress tension and worry are the order of
the day. Amenorrhoea due to stress of work,
tension before examinations or stoppage of
periods after hearing a shocking or bad news
are too commonly seen. Shock occurring after
obstructed (complicated child birth) labour or
severe bleeding after delivery (PPH)-produces
necrosis of the anterior pituitary by causing
thrombosis/spasm of blood vessels supplying
the pituitary leading to pituitary failure and
amenorrhoea. (Sheehans syndrome).
(f) Overanxiousness to conceive in patients
nearing menopause as they know the time is
running out may produce subjective
symptoms of pregnancy like amenorrhoea,
morning sickness, breast secretion, feeling of
foetal movements. All these imaginary
symptoms occur in pseudocyesis where
psychic factors related to denial of the feminine
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role play a part in one way or other.
(g) Amenorrhoea can be due to iatrogenic
causes. Excessive vigorous curettage probably
after induced abortion leading to destruction of
the endometrium producing intra-uterine
synaechiae called Ashermans Syndrome
which causes amenorrhoea. Many illiterate
woman complain of amenorrhoea after an
operation. On examination LO!! The uterus is
absent as it was removed and the patient was
not aware of it.
(h) Lastly loss of love object has been reported
to be responsible, in vulnerable women, for
raised emotional tension leading to repression
of the ovarian cycle and oligomenorrhoea
(Masani 1966). The hypothesis is strengthened
by the observation that large number of
displaced persons from Pakistan during the
partition of India suffered from secondary
amenorrhoea. Loesex(1943) made a similar
observation in case of missed periods following
aerial bombardment of London in the
2
nd
World War.
Still the aetiological causes of pathological
amenorrhoea are incomplete. Only those relevant
and observed in day to day life have been listed.
DYSMENORRHOEA
Dysmemorrhoea means painful menstruation
popularly known as spasmodic dysmenorrhoea.
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Pain is a subjective symptom and hence cannot
be assessed objectively. Different women react to
the same pain in different ways and in the same
woman, the perception of pain varies with her mental
state.
Slight discomfort and pain during menstruation
is common. In dysmenorrhoea the pain is severe
and colicky in nature accompanied by abdominal
distress, backache and radiates towards the thighs.
In very severe cases, in addition there may be
nausea, vomiting, migraine, tachycardia, anxiety
attacks; the patient may go into a state of shock or
dissociative fits or fainting spells.
The incidence of dysmenorrhoea is affected by
social status, occupation and age. The inherent pain
threshold varies from one individual to another. N
women who belong to the high social class, who are
delicate and suffer from emotional tension and
anxiety and are high strung, the pain threshold is
low. Even a slight discomfort is experienced as sever
pain. A girl who is only child is more likely to suffer
from dysmenorrhoea.
Faulty outlook and upbringing play a very
important role in dysmenorrhoea. It is often said that
A dysmenorrhoic mother usually has a
dysmenorrhoic daughter. Her outlook towards
menstruation is wrong. She is trained to treat
menstrual period as an ill-time of the month. The
expectation of pain is fostered by over-anxious
parents. This is because the girl has not been
explained and educated regarding the physiological
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nature of menstruation. This knowledge of
physiology of sex, if given to the girl before
menarche, the first period does not come as bolt
from the blue as she is mentally prepared.
In some parts of our country she is also treated
as an untouchable, kept outside and segregated and
is made to think that she is not fit to mix up with
people, let alone partaking in any religious function.
Is it not unfortunate that such a false belief should
still exist in our society? The girl gets a feeling of
disgust and revolt and is psychologically upset and
this adds to the causation of pain.
Circumstances which lead to nervous tension
make dysmenorrhoea worse, even if they do not
cause it. These include unhappiness at home or
work fear of losing an employment and anxiety over
examinations. It is said that marriage and child birth
cure dysmenorrhoea. Certainly marriage may cure
by removing tension of a long engagement and by
providing happy security. Of late, may patients are
complaining of dysmenorrhoea for the first time after
marriage. Maladjustment, dissatisfaction with
married life, ill treatment by the in laws, impaired
adaptation in the family are important causes.
Dysmenorrhoea is the outer manifestation of an
inner revolt or suffering. Denial of the feminine role in
some cases and in others dysmenorrhoea acts as a
defence against being a woman.
The problem of dysmenorrhoea is not the same
everywhere. Incidence of girls complaining of
dysmenorrhoea considerably decreased in the west
due to various socio-cultural changes. The increased
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freedom in expression of sexual needs and
behaviour in the west has lessened the
psychological burden formerly imposed on women.
In the east, dysmenorrhoea is still a very commonly
encountered menstrual disorder. Considerable
evidence has been presented to suggest that
dysmenorrhoea is likened to the suppressed
sexuality and social constraint on the expression of
the sexual needs in the eastern society. In one
study, two thirds of the patients complained of
unsatisfactory sexual relationship along with intense
craving for sex. This may be so in married
individuals.
In our country cases of dysmenorrhoea occur in
young girls at an age where their concentration is not
so much on sex but on academic courses and
examinations etc. The dysmenorrhoea may even be
an excuse to avoid something which is disliked.
Proper upbringing of the children is very essential.
And they also must be taught the physiology of
menstruation and that menstruation is the sign of
good health and not a period of ill health.
Dysmenorrhoea is also observed in women
who are unmarried, having a career or working in
offices and leading a sedentary life. Some of them
have to work in order to support the families and
may be the only earning member. Parents in turn
also do not even think of getting them married. In a
way it is a sort of sacrifice on the part of these
women. As our elders say that every thing should be
done at the correct time, so the marriage of girls at
the right age is no exception.
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ENDOMETRIOSIS
Endometriosis is a condition when th3e endometrium
is present outside its normal habitat i.e. the mucous
membrane lining the uterine cavity. If the
endometrium is present in the musculature of the
uterine cavity it is called as uterine endometriosis or
Adenomyosis. If the endometrial tissue is present
outside the uterine cavity it is called as the extra-
uterine endometriosis. Extra uterine endometriosis
can be pelvic or extra pelvic and occurs in the
following:-
Pelvic Extra
pelvic
Ovaries,
tubes umbilicus
pelvic
peritoneum laparotomy scars
cul-de-
sac, intestine, bladder
uterosacral ligaments limbs
(arms)
rectovaginal
septum sigmoid colon
Appendix
thorax lung
Pleura
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endocardium
Of all the sites in the pelvic, ovarian
endometriosis is the commonest and next in order is
in the pouch of Douglas. These are the sites on
which endometrium can fall and get implanted, when
there is retrograde menstruation through the
fallopian tubes into the pelvic cavity (Implantation
theory). When once it gets implanted and survives
endometrium has a unique property; i.e in the
prliferative phase of menstrual cycle (first half) the
endometrium proliferates and in the secretory phase,
it un dergoes secretory change and during
menstruation it bleeds. In that process it produces an
inductor substance and spreads to the surrounding
areas. In the ovary it invades the cortex of the ovary
and burrows into it and forms a cyst and as a result
of repeated menstruation this cyst becomes
enlarged and is known as chocolate cyst of the
ovary.
In the pelvic cavity in extreme cases the whole
pelvic peritoneum is affected with areas of
haemorrhage followed by puckering and scarring
and the whole pelvis and become a frozen pelvis as
a result of endometriosis. As a result of these
changes the patient suffers from severe pain during
periods i.e. dysmenorrhoea, profuse bleeding i.e.
menorrhagia and dyspareunia (pain during
intercourse). Even in remote areas like umbilicus it
forms a nodule which becomes gradually bigger with
each menstruation and the same occurs in other
areas. If it affects the bladder there will be
haematuria during menstruation. It can produce
symptoms of intestinal obstruction if it affects small
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or large intestines or rectum.
In the uterus itself, bleeding of the endometrial
glands in the musculature of the uterus causes
reactionary hypertrophy and hyperplasia of the
uterus. Uterus becomes bulky and enlarged and
may contain occasionally a tumour called
endometrioma or adenomyoma in the musculature.
All these changes, as in cases of pelvic
endometriosis produce symptoms like menorrhagia
and dysmenorrhoea.
Endometriosis is essentially a disease of the
child bearing period. It does not occur before puberty
and regresses after menopause i.e. ovarian function
is essential for its occurrence. Whatever be the initial
genesis of endometriosis, its further development
depends upon the presence of hormones mainly
oestrogens.
Apart from the implantation theory described
above the theory of coelomic metapalsia
propounded by Meyer and Ivenoff explains the
occurrence of endometriosis. it is a strange
embroyonic fact that germinal epithelium of the ovary
and the periotoneum musculature and mucous
memberane of the tubes and uterus is derived from
the same analge of the coelomic epithelium. Under
some unknown stimulus endocrine or otherwise, the
peritoneal or gonadal epithelial cells become
differentiated and get invaginated to resemble
uterine mucosa or tubal mucosa. Meigs and
Goodal suggested that the cause of metaplasia of
the coelomic epithelium is a continuous
hyperoestrinism a physiologic response to
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abnormal uninterrupted menstrual cycles. They
believe patients should not menstruate as often as
they do without a period of amenorrhoea associated
with pregnancy. They think that endometriosis is the
penalty of our present civilization and the economic
factors which prevent early marriage and frequent
child bearing. They point out that we are allowing
young women in the privileged class to avoid
pregnancy. This in turn is conducive to sterility and
endometriosis. In support of this theory they brought
out the well recognized fact of frequency of
endometriosis among patients of higher social and
economic strata of society as observed in private
hospital records (4 times more) in contrast to it
incidence amongst patients in charity hospitals. Prof.
Meigs used to exhort all young women to get
married early and have the first baby early.
Thus endometriosis is a scourge of the private
patients. These women and others in the higher
social group are also those likely to postpone child
bearing and present with symptoms of
endometriosis. Pregnancy causes atrophy of the
endometirum chiefly through higher progesterone
level and cures the condition.
What was said nearly 40 years back by Prof
Meigs is valid even today. At one time endometriosis
was not a problem in our women but of late the
incidence of pelvic endometriosis has increased
considerably in our own country because of late
marriages and conception.
Thus endometriosis is one of the most
mysterious and fascinating disorders. The disease
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owns a unique pathology of being a benign
proliferative growth process having the propensity to
invade normal surrounding tissue like a cancerous
growth. Even in its own house (swasthaan) it can
invade the wombs musculature like a cancer (or a
carbuncle) and start producing problems even
though the endometrium and the musculature are
derived from the same coelomic epithelium. What is
more, it can occur in the remote and far off places in
the body like thorax and upper limbs etc.; like cancer
metastasis as if the endometirum seems to be all
powerful and omnipresent.
GENITAL PROLAPSE
Prolapse is downward descent of vagina and
uterus and is a common and disabling condition.
The occurrence of prolapse implies failure of
one or more supports of the uterus or vagina. In 95%
of cases of prolapse the patient is multiparous
implicating child bearing as an important casual
factor.
Supports of the uterus: There are two main
supports of the uterus:
(a) Muscular
(b) Ligamentous
Muscular: The pelvic floor consists of two levator
ani muscles. These muscles have three parts
Pubococcygeus, iliococcygeus and ischiococygeus.
The pubococygeus is the most important of the
three. Inner fibres of this (called peubo-rectalis)
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decussate below the rectum and form a sling and
these along with the anal sphincter that contract and
help at the end of defecation in everyday life.
They have no rest and relaxation and no
spacing in between pregnancies. Naturally their
muscular and ligamentous strength will be poor.
(c) Injury during child birth: Undue stretching of
the pelvic floor, application of foreceps or (vacuum)
before full dialation of the cervix causing
overstretching or tear of the ligamentary supports;
downward pressure on the fundus during attempt to
deliver the placenta; laceration of the perineal body if
unsutured will widen the hiatus urogenitalis and also
the delivery of a big baby. All these have naturally an
effect on muscle and money power; either the power
is weakened or exhausted in which case prolapse is
bound to occur.
(d) Raised intra-abdominal pressure as it
occurs in large tumors like fibroids and ovarian cysts
or sometimes due to chronic cough etc. makes the
power being pushed down by a heavy weight
constantly pressing downwards.
(e) Most of the prolapse cases usually occur
after menopause. Until that time the supports (both
muscle and money power) remain adequate but the
atrophy which follows cessation of the ovarian
function is the final straw and is followed by prolapse
within a few years.
All the recent work point out to the conclusion
that parturition has the capacity to cause partial
denervation of the pelvic floor and that this is a
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substantial fact in the aetiology of prolapse.
Mother nature has provided a cushion of
endopelvic facia for the other two organs bladder
and rectum which are put to the strain of stretching
(expansion and contraction) during everyday life. In
addition pubocervical ligaments support the bladder
and the puborectalis supports the rectum. If these
are damaged during child birth along with the uterus
they also prolapse. If the bladder comes down it is
called cystocele and if the retum prolapses it is
called rectocele. If the levator plate is cut even
complete rectal prolapse occurs.
PREVENTION
This is one of the conditions where bad
obstetrics leads to gynaecological conditions. Proper
care during pregnancy, careful supervision and
management of second stage of labour including
timely episiotomy or low forceps delivery if there is
any delay at this time; avoidance of Credes
expression of the placenta in the third stage and
timely proper suturing of he perineal tears go a long
way in the prevention of prolapse. Early ambulation
and post natal exercises and advice regarding family
planning and spacing are essential after the delivery.
In my opinion a maternity leave of three months is
quite inadequate and all pregnant women who are
working in different spheres should get at least six
months of paid maternity leave to recoup their health
and also to look after their children.
MANAGEMENT
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Of the many operations performed today for
the treatment of prolapse, vaginal hysterectomy and
repair of the vault and pelvic floor constitutes one of
the most commonly accepted procedures.
Occasionally one may have to do a vaginal
hysterectomy for a benign condition called
dysfunctional haemorrhage. In both the above as we
proceed from below we have to cut and suture the
uterosacral ligaments first, then Mackenordts next
and the broad ligaments afterwards to remove the
uterus. In short, uterus can only be removed after
severing all its supports. As we cut each one of the
supports uterus comes more and more down. After
removal of the uterus, the gap has to be
reconstituted by bringing all the ligaments on both
the side, and suture them together so that a buttress
is formed which prevents vault prolapse and after
that the vagina is sutured.
The same thing is being observe din todays
practice more so in politics. If any one has to be
brought down all his supports are withdrawn (ir cut)
either by hook or by crook. In short the money and
muscle power withdrawal is the first essential step in
the process.
OVARIAN TUMOURS
Cystic enlargement of one or other normal
ovarian structures is so common as to be regarded
as physiological. It is rare to see the ovary of a child
or adult woman without one single cyst in it. The
mere finding of a small cyst in a ovary should not be
regarded as indicative of any significant pathology.
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Failure of the surgeons to recognize this
fundamental fact has led to many women having a
normal ovary removed in the course of
appendicectomy. Many more ovaries have been
sacrificed for possessing a normal corpus luteum
Jeffcoate
Of late ultrasound scanning has become so
frequent for the diagnosis of various
gynaecological conditions. The report often shows
one or other ovary slightly enlarged and cystic. It
requires a great understanding of the physiology
and pathology of the ovarian tumours before one
should advice any surgery on these patients.
OVARIAN NEOPLASMS
The ovary consist of sex cells which are
totepotential and of mysenchymal cells which are
multipotential. So when the ovary becomes
neoplastic almost any sort of tumour can result. O
other organ in the whole body has this unique
property. Some tumours called Teratoma contain
all types of epithelium ectodermal, entodermal
and mesodermal. The ovum has got the property
of even self fertilisation (parthenogenesis) and
even chorionic tissue or foetus can be present in
the tumour. Is it not amazing?
Ovarian tumours can occur at any age and
can be of any size upto 50 kg or more.
Malignancy does not depend upon the size of the
tumor. No ovarian tumor is to be taken as benign
unless the histological examination of the tumour
is done.
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OVARIAN TUMOURS
These can either be solid or cystic and
some are both cystic and solid. They can be
benign or malignant. So long as the tumour is
within the pelvis it may not produce any
symptoms. But when the tumour grows-becomes
moderate in size-then it develops a pedicle and
raises above the level of the pelvic brim. Then the
tumour acquires a much greater degree of
mobility and is therefore more prone to undergo
torsion or axial rotation. It is not uncommon for
the tumour to be rotated through three or more
complete circles. Tumour becomes congested,
internal hemorrhages occur, adhesions form to
intenstines or ormentum and the cyst may
become infected. These adhesions can contribute
to a new blood supply to the tumor, which when
severed from its original connection then
becomes a parasite.
As I teach the subject to the students I am
always reminded of what is happening and what
we see in everyday life. Whatever may be the
type of tumour-so long as it is in the protection of
the pelvis it does not undergo torsion; only when it
develops a tail or pedicle and when it comes out
of pelvis and acquires mobility then only this
complication occurs. So long as the children are
under the protective influence of the parents
(usually upto 10-12 class) students do well. But
once they go to the college, they get a pedicle or
a tail usually a moped or a motor cycle. The
atmosphere in the college is also such that they
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have so much freedom to move about. Also the
students who stay in the hostel for the first time
feel that they have freedom from the strict
observance at home. Then one sees all the
complications like torsion or axial rotation
observed ion the ovarian tumours also occurring
in the students. The rock and rool starts, the twist
occurs, the break dance and disco follow leading
some unfortunate ones giving into the habit of
taking drugs ec. And ultimately leaving the
parents and becoming one in the company of
others like the parasitic tumours. Howe easy it is
to fall into bad company! Most of the times it is the
parents to be blamed for such a mishap. They are
occupied in their own social activities and parties
and the children often get neglected. In this most
vulnerable and crucial period in a students life the
guidance and attention of the parents are very
essential if they want their children to achieve
something worthy in life.
CANCER OF CERVIX
Cancer of the Cervix is a disease with
fascinating aetiology. The exact cause of the
cervical cancer is not known. However it is
interesting to understand the evolution of this
cancer.
The vaginal portion of the cervix is lined by
squamous epithelium and the cervical canal by
the columnar epithelium. The demarcation
between the two epithelia is the squamo-
columnar junction at the external os of the cervix.
For some unknown reason a war of attrition
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goes on between these two epithelia. In the intra-
uterine life in the earlier weeks the canal is lined
by transitional (squamous) epithelium. In the latter
weeks of gestation the columnar epithelium
pushes the squamous epithelium right to the
external os and it times beyond the external os
giving rise to what is termed as congenital erosion
of cervix.
When the woman grows up and gets married
and becomes pregnant, because of excessive
production of hormones there can be marked
proliferation of the columnar epithelium, again
producing vascular erosion of cervix. As a result
of infection of the cervical anal the squamous
epithelium becomes denuded, but is quickly
occupied by the columnar epithelium. However
when the infection is treated and the patient
recovers, the squamous epithelium pushes back
the columnar epithelium into the cervical canal. It
does so by undermining the columnar epithelium.
While so doing, at times it blocks or invades the
cervical glands. Thus the junction of the two
epithelial zones is a labile transformation zone.
Cervical carcinoma begins in this zone. The
reserve cells lying beneath the columnar
epithelium at the squamo columnar junction form
metaplastic cells in the transformed into mature
epithelium but in some instances there is
epithelial unrest and become atypical change
that precedes dysplasia and cancer. This is how
the cervical intracellular neoplasia starts. The
dysplasia is mild in the beginning, then becomes
marked and later becomes severe leading to
carcinoma-in-situ or preinvasive cancer and
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subsequently frank invasive cancer.
Cervical cancer is more common in low
socio-economic class and virtually non existent in
celibate population. Its incidence is more common
in women whose coital activity and child bearing
start early.
There is an association of the disease with
sexual behaviour and although the age of first
pregnancy, parity and promiscuity all seen to be
relevant aetiological factors, it is likely that an
early age of first intercourse is the most important
factor.
An equally important factor is the number of
sexual partners and this appeared to be the case
quite independent of the age of first sexual
intercourse. Rare incidence in nuns, Jews in
whom the male partners are circumcised
indicate diminished risk of exposure to smegma-
though there is no evidence that smegma is
carchnogenic.
Again, high incidence is observed in women
attending venereal clinics due to Herpes
Simplex virus and Human Papilloma virus.
Erosion of cervix, ectropion, trauma,
endocervicitis are all precursors of cancer of
cervix.
It is unfortunate that in the pre-invasive stage
there are no symptoms at all. By the time
symptoms like bleeding appear, cancer already
becomes invasive. The bleeding that occurs in
inter-menstrual bleeding superimposed on normal
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periods and it also occurs after intercourse.
I really wonder as to why the Lord made
spotting/bleeding as the first symptom.
Irregularities of periods is so common at this age,
many women think such type of bleeding is
common before menopause and the patient
delays consulting the doctor. Also many or our
women are reluctant to get themselves examined
and are treated with drugs to control bleeding for
quite some time and in the end only to know that
the disease is already advanced.
Pain is the last symptom to appear it
occurs when the cancer spreads to parametrium
and affects the nerves splanchnic plexus or
when the cancer spreads to viscera like bladder
ureter or rectum. If only the Lord made pain the
first symptom, many women would have come to
the hospital/gynaecologist earlier; and the
condition would have been diagnosed and treated
at a very early stage. Mysterious are the ways of
Lord.
It is also the one cancer that by virtue of its
accessibility can be readily diagnosed even in the
pre-invasive stage and if treated in early stages
can often be cured. Papinacalou who gave his
name to this Papsmear laid the foundation for
preventive medicine at its best. But how many
practising doctors are doing a simple speculum
examination (visual screening) for their patients?
By this alone as many as 70% of cases of cancer
cervix can be detected at an early stage and
many lives can be saved. If a routine Papsmear
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cannot be done as a screening process it
should be done in all high risk cases and in those
who have post coital bleeding or there is bleeding
after making a pelvic examination.
Any precancerous lesion like marked
epidermadization, dysplasia and basal cell
hyperplasia and also in those women having a
severely infected cervix with marked erosion-
especially in women over 45 yrs of age, demand
a hysterectomy.
What is amazing is that the two epithelia, the
squamous epithelium lining vaginal portion of
cervix and the columnar epithelium lining the
cervical canal are both derived from the same
ceolomic epithelium children of the same
mother. Even then they are at war with each other
from the beginning and the line of demarcation or
actual line of control is the squamo-columnar
junction. This is what exactly is happening at our
countrys (Indo-Pak) borders today. In trying to
take control of others land some reserve cells
which are normal otherwise become militant
grow up and this ultimately leads to insurgency
and finally develop into cancer.
DISEASES OF URINARY SYSTEM
There is a close relation between genitalia,
urinary organs and the uterus and its appendages
during early intrauterine life. Urinary tract
anomalies are often associated with genital tract
developmental anomalies.
Anatomically, the bladder lies between the
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uterus and the symphysis pubis, being separated
from the body of the uterus by the utero-vesical
pouch of the peritoneum. The urethra passes
downwards and forwards from the base of the
bladder behind the symphysis pubis to end into
the external meatus. The external urinary meatus
opens into the vestibule of the introitus below the
clitoris.
It is this closeness to the introitus that makes
the urethra vulnerable to infections like
gonorrhoea, Chlamydia, trichomonas, and
candida and sexually transmitted diseases.
Urethritis is a common accompaniment of all
these infections. Vigorous and frequent
intercourse often aggravates the problem.
Honeymoon cystitis is a distinct clinical entity
following coital injury to urethra and bladder base.
Menopausal women who suffer from thinning of
the vaginal epithelium and mucosal lining due to
oestrogen deficiency are also susceptible to
trauma and infection leading to urethritis.
It is because of the same nearness of the
urinary tract to the genital tract that in certain
gynaecological and obstetric conditions like
haematocolpos, retroverted gravid uterus, pelvic
haematocele in ruptured ectopic, tumours either
fibroid or ovarian cysts impacted in the pelvis or
even in cases of marked procedentia of the
uterus, that retention of urine occurs.
The urinary system derives no benefit from
pregnancy and occasionally the reverse. Certain
physiological and anatomical changes occur as a
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result of pregnancy which may bring latent
pathology to light and may encourage the
development of a fresh urological handicap. In a
previously healthy woman, control of micturition
may be undermined and subsequently recurrent
attacks of urinary infections originate in the
urinary stasis an inevitable part of normal
physiology of pregnancy.
It is again due to the same nearness of the
urinary tract, trauma can occur during labour
leading to descent of bladder cystocele,
urethrocele, etc. giving rise to various symptoms.
An extreme form of trauma can occur due to
contracted pelvis or cephalo-pelvic disproportion.
In these cases the bladder gets compressed
between the foetal head and the pubic symphysis
followed by ischaemic necrosis of bladder.
When the slough sepaerates, a vesico-vaginal
fistula occurs and the patient complains of
constant dribbling of urine and there is no control
over the act of micturition i.e. true incontinence of
urine. Injury to the bladder followed by the vesico-
vaginal fistula can also occur after obstetric and
gynaecological operations. The duration of
incontinence varies from a few weeks in one
patient to even as long as 25 years in another
patient. It is a miserable condition as the woman
smells of urine throughout and is often boycotted
by her family and society. This type of obstetric
fistula is totally preventable by care during
pregnancy and labour.
The above condition denotes one thing, that
the bladder cannot stand any insult. It
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immediately stops functioning leading to
incontinence of urine irrespective of the fistula
being a small or a big one but the amazing part is
even after so many years of incontinence if the
bladder can be cajoled and the fistula is repaired
and sutured successfully, bladder regains its tone
immediately and starts functioning. In short there
is no disuse atrophy in case of the bladder an
exception to the rule.
It is also a paradox to observe that the
bladder gets lazy when day in and day out it is not
evacuated (emptied) at regular intervals as it
occurs and is observed in working women who,
for some reason or other, had no time to go to the
toilet the whole day leading to so called Lazy
Bladder Syndrome. These women are being
trained how to empty their bladder by exercises or
occasionally even by catheterisation. Does the
above confirm the old saying A bladder makes a
good servant but a bad master and bad habits are
easily acquired!.
It has been said in our Shastras there is a
particular type of dosham (blemish) called
sahavasa dosham (blemish arising from
proximity). This occurs by being very close to
someone, one may have to suffer from the ill-
effects of the other as is seen in case of urinary
tract subjected to infection and trauma by being
very close to the genital tract.
Unequal combination is always
disadvantageous to the weaker side; said Oliver
Goldsmith in Vicar of Wakefield in this case, the
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urinary bladder.
PREMENSTRUAL TENSION
Most well adjusted women experience minor
psychological and somatic changes for a few
days preceding menstruation. These menstrual
molimina give way to a sensation of well-being
once menstruation is established. Psychoneurotic
woman incorporate menstruation into their
disorder, as they do unpleasant somatic stimuli
with the result that its general manifestations
become exaggerated to constitute a premenstrual
or menstrual tension state.
The condition is often observed in women
aged 30-45 years. The symptoms start 7-10 days
premenstrually. The complaints are varied and
include irritability, lassitude, malaise, headache (a
type of migraine), gastro-intestinal upset such as
colonic spasm and constipation, frequency of
micturition and a feeling of fullness in the breast,
abdomen and they also complain of insomnia,
emotional outburst and congestive
dysmenorrhoea.
Whether the premenstrual tension is the
cause of the individual misery and family
disharmony or the result of the above is not clear.
Certainly the stress of modern life, soaring cost of
living and one mans income not being sufficient
to meet the expenses of the household, all these
tell upon the women there is nearly always a
fundamental constitutional and inherited
weakness which makes the individual fail to cope
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with the ordinary day to day stresses of life.
In a few, the symptoms can be traced to
some nervous shock or domestic upset or a
lurking suspicion about the husband being
unfaithful to her, trying to ring up and find out
about his whereabouts. In the bargain she nags
and scolds the children and becomes upset over
even very small trivial things. These periodic
outbursts and moods result in quarrels between
the husband and wife which make the situation
worse. It is the imaginative woman living in her
nerves who is most likely to suffer.
The third type of woman is a working woman
who toils the whole day in the office and has to
work hard again in the house looking after the
husband and the children and in-laws who show
no sympathy for her.
Actual cause of PMT is not clear whether it
is due to high oestrogen or low progesterone or
an imbalance between the two; other factors
include deficiency of vitamin B6.
Whatever be it, one should know that day to
day life consists of little things and one should not
get upset and make a big mountain of a mole hill.
There will be periods of suffering and hardship;
and one should know how to bear them. There is
no pleasure without pain and they go together. At
all times one should be content with what one has
(Santushtam satatam yogi Bagavad Geeta Ch.
12) and the supreme faith in the Lord Almighty
makes one cross over the various hurdles of life.
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MENOPAUSE
Menopause and climacteric are often used
synonymously. Menopause means cessation of
menstruation and climacteric means ring of the
ladder meaning crucial period of life.
Climacteric is the equivalent of perimenopause
which may start 5-10 years before menopause
and continue upto 5-10 years afterwards.
The most characteristic symptom of the
climacteric is the hot flush: an uncomfortable and
sometimes unbearable feeling of intense heat of
sudden onset usually arising in the trunk
spreading upwards towards the neck, face, and
forehead and sometimes over the whole body
followed by intense sweating. When this occurs at
night, the patient is woken up and may be more
aware of sweating and complains of night sweats.
Other symptoms include headache, insomnia,
depression, tension, irritability, aggressiveness,
nervous exhaustion, fluctuations in mood sense of
frustration and feeling of decreased energy and
drive, reduced powers of concentration and
feeling of inadequacy and loneliness.
Many factors influence the approach to
menopause like the woman being single or
married or childless or is surrounded by
grandchildren and happy family. For the barren
and unmarried woman menopause represents the
end of the reproductive era. Married women
sometimes get worried by the idea that
menopause means the end of sexual desire and
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physical love.
Psychological response depends upon the
social and cultural background. In Arab countries
menopause is welcome because women are no
longer regarded to be contaminated by menstrual
blood. In our country women with their
philosophical attitude welcome menopause as
they are free from the periods (menstruation is
thought as a curse inflicted upon women) and
become no more untouchables and now fit for any
religious function (some temples cannot be visited
by women in their reproductive period). Women in
this age group are being respected and regarded
as elders, and so also in some African countries.
Even so, because of ignorance and fallacious
ideas many women approach menopause with
dread. They fear of insanity, loss of feminity and
beauty, loss of their husbands affection and
associate menopause with the development of
cancer. It is considered as a finger-post to old
age.
As with the case of women with
Premenstrual Tension Syndrome, menopause
is also a period of stress in the home. Children
are at an age when they cause much anxiety,
(often needless) and increasing expenses; they
also go abroad for higher studies, and the
presence of girls yet to be married also adds to
the stress of their life. The husband as usual is
busy with his office/professional work. Women get
a sense of frustration, feeling of decreased
energy and drive, reduced power of concentration
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and feeling of loneliness and isolation Empty
nest Syndrome. All these are reflected in the
changes of mood like irritability, depression and
tension etc.
In some, the thought that many of lifes
expectations in terms of money, marriage and
position may never have been fulfilled. Truly the
patients problem is one of a mixture of hormone
dependence and life stress syndrome. It should
be emphasized to women that menopause
represents a change of life and not the end of life.
Unless willed otherwise libido remains
unchanged, women can have satisfactory sex and
menopause will not result in women being
suddenly looking aged and unattractive.
This period should not be regarded as the
Vanaprastha(the stage of life when elders retreat
from family responsibilities and go to live in
forests in search of spiritual solace). Women
should utilize their time reading, attending
religious discourses, doing social work, spend
time with the grandchildren, moulding them to be
good citizens of tomorrow. The attitude of the
obstetrician in general should be one of great
sympathy and understanding in removing their
doubts and innate fears and impress upon them
that this is a period for achievement and maturity.
There is a gradual increase in aging
population. It is expected that by 2000 A.D., 5% in
developing countries and 13% in developed
countries will be over 65 years of age. Women
live longer and it is important that their health
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status during 20-30 years of post menopausal
period of life, is reasonably well maintained. To
that extent there is need to establish Mature
womens Clinics or Menopause Clinics where a
physician, psychiatrist and obstetrician and
gynaecologist will look after these women. The
aim of these clinics is not only to treat
menopausal symptoms with hormone
replacement therapy, (but also prevent fractures
and myocardial infarcts to which they are more
prone), also with a positive aim of enabling and
encouraging women to keep physically and
mentally fit and to maintain confidence, interest
and zest for life so as to be better able to enjoy a
full and happy life into advanced age.
The syndrome of menopause is not confined
to women only. Men in their advanced age are
also prone to the same reactions in life. Perhaps
the sudden though not unexpected retirement
with a drop in ones social status are factors
comparable to the problems of menopause that
women face in their life.
CANCER OF THE BREAST : VITAL ROLE OF
GYNAECOLOGIST IN SCREENING & EARLY
DIAGNOSIS
The thought of cancer of the breast reminds
me of four cases. Surprisingly three of them were
doctors (of these, two being gynaecologists) and
the fourth the wife of a doctor. All of them were
hardly 40-45 years of age at the time of diagnosis.
One of the gynaecologists kept her condition
secret (probably for fear of publicity), to such a
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late stage, that bone metastasis occurred in the
vertebra. She had a pathological fracture while
applying forceps in a delivery case.
While it is so in doctors or with doctors
wives, one can only imaging how many more
cases are being missed or diagnosed late in other
educated people, let alone uneducated and lay
people. Compared to other cancers, such as
cancer of the cervix or cancer of the ovary, the
diagnosis should be easy and early as the breasts
are easily accessible for examination but it is
not so why? Is it because women neglect a
small lump thinking it is of no significance or do
they feel shy to get their breasts examined or they
are afraid that if it turns out to be malignant,
others will come to know about it. Whatever may
be the reason for late diagnosis, one feels sad
about it.
The breast is a part of the reproductive
system and therefore concerns the obstetrician
and gynaecologist. One in five seeks medical
consultation for breast problem and one out of
fifteen patients is likely to develop breast
carcinoma at some time during her adult age.
Considering that breast carcinoma is the second
commonest cancer (next only to cervical
carcinoma) in our country, the gynaecologist is in
the best position to undertake the responsibility of
detecting suspicious lesions of the breast.
The mature female breast is vulnerable as it
is a dynamic endocrine target organ profoundly
influenced by the fluctuations of hormones
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oestrogen and progesterone of even the normal
menstrual cycle. It is again the hyper and/or
continuous oestrogen unchecked by progesterone
that plays an important role in the aetiology of
breast cancer as it is evidenced that carcinoma of
the breast is more common in nulliparous women;
women who had early menarche or late
menopause; association with endometrial
carcinoma and lastly, high incidence in those
where there is misuse of oestrogen in the desire
for retaining feminity for ever. In addition to the
above, there is sufficient evidence to show that
cancer of the breast runs in families, implicating a
genetic pre-disposition.
The gynaecologists role starts from advising
the girls as to the right age to get married; to
have the first child at a younger age and also
encouraging the mother regarding breast feeding, as
these are protective factors against development of
breast cancer.
The gynaecologist provides primary health care
to many women as it is he whom women consult
whatever their problems are, which include infertility
work-up, contraceptive counselling, family planning,
pregnancy and lactation and any gynaecological
problem at the time of pre and post menopausal
period. These offer an important opportunity to
provide women with the latest information
concerning breast diseases, more so to discuss risk
factors regarding breast cancer.
Physical examination of the breast and
motivating the patient for performing self-
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examination and to refer her to mammographic
screening are prime important things to be done for
early diagnosis of breast cancer.
Recent data have shown that breast self-
examination is related to earlier detection of cancer
and improved survival rates. Herein lies the
importance of the gynaecologist to assume the role
of an educator in teaching women on systemic
approach to self-examination. These include advice
as to when to do the examination (preferably
following menses as the breasts will be less tender
and enlarge), position of the patient, duration of
palpation or search period, the correct palpation
technique of all quadrants of the breast and the
discrimination between normal and abnormal tissue
and also to encourage the patient to continue
periodic and regular self-examination. Importance of
attention to areola and nipple should be told. If
present, the discharge should looked for quantity,
viscosity, colour and presence of blood and a
cytological examination of the discharge is
imperative in such cases. Breast self-examination
should be made habit-forming by the age of twenty
in high risk-prone cases and certainly by the age of
35-40 in all women, and should be mandatory in all
who are on hormone replacement therapy for
menopausal symptoms.
It is now well established that mammography as
a screening method is the most accurate technique
for detecting early stage cases. Even lesions less
that one centimetre and also clustered
microcalcifications associated with malignant lesions
can be detected by this imaging technique, while
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ultrasound is useful in differentiating solid and
ultracystic lesions and in enabling successful
aspiration and fine needle biopsy. Basal
mammography at 35-40 years (and earlier in
patients at risk) and later every two to three years,
upto the age of fifty years and annually thereafter is
advised.
What is needed today is to make people in
general and women in particular aware and
conscious of how simple non-invasive procedures
like breast self-examination and mammography can
detect lesions of the breasts at an early stage.
Stress should also be laid on not neglecting even a
tiny small nodule in the breast, even if there are no
symptoms and that any lump in the breast at any
time should be removed and biopsied Save the
breast from cancer campaign should be started and
probably the establishment of the institutions to care
exclusively for the problems of the breast may go a
long way in saving most women who fall a victim to
this most common and dreaded condition of cancer
of the breast.
In a broader perspective, safe motherhood
should not only involve in reduction of maternal
mortality and morbidity but it should encompass the
total health care of all women including nutrition,
literacy, health education, family planning,
community development and integration of traditional
and modern health-care systems including
prevention and early diagnosis of malignancies of
female genital tract and breast and thus should aim
at improving the quality and safety of the lives of girls
and women.
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SEX EDUCATION
Any consideration of sex education requires the
understanding of the changes that occur during
adolescence and puberty. Adolescence is the period
of life during which a carefree child becomes a
responsible adult. The modern description of the
adolescence is the Teen ager. Puberty is a growth
phase characterised by physical sexual
differentiation and by the onset of activity of sex
organs. It is really the first part of adolescence, the
remainder being concerned with mental and
emotional adaptation to sex function and with the
development of full maturity. The menarche is the
onset of first menstruation and is one of the
manifestations of puberty.
Three important phenomena occur during this
period:
(a) Physical growth; i.e. sudden spurt in
stature just before or after menarche.
(b) Sexual differentiation i.e. development of
the breasts and pubic and axilliary hair, the
body contour change by the deposition of
fat.
(c) Development of the genital tract.
(d) The phase of active physical growth
makes the girl temporarily confused and
embarrassed regarding the change and she
becomes awkward in her movements. Her
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figure becomes more full and feminine as a
result of surge of hormones and her voice
changes from the shrill voice of childhood to
that of slightly deeper and more melodious
of the adult. Soon she develops self
consciousness, is interested in her
appearance, becomes more curious and
imaginative and also may be moody and
secretive. Sex gender identity occurs and as
she grows up the curiosity about sex
increases and the sex urge becomes
gradually manifest.
While the girl regards herself as fully grown
up, she looks for independence and wants to
assert herself in receiving and obeying orders.
She does not like to be snubbed. Yet physical and
emotional maturity are not attained until several
years after menarche.
Tact, proper advice, kindness, sympathy and
due consideration given for her views at the same
time strictness within limits, go a long way to
ensure that a balanced adult emerges from this
testing period. Affection and trust should take
place of commands. She should be encouraged
to be continually occupied in either work or
healthy recreation. The girls become very
sensitive for any comment regarding their figure,
looks and the development of the breasts. All
parents must be ready to accept these changes
and guide them, and train them so that their
daughter can in future fulfil the role of a wife and
as a mother. As such it is the parents duty to
explain to the girl regarding the onset of
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menarche, the physiology of menstruation and the
phenomena that accompany, so that the girl can
be primed as to what to expect and can accept
these with pride.
The onset of menstruation in a girl who is
uninformed arouse emotions of fear and shame
and gives her a psychological shock from which
she never fully recovers. She should also be
instructed regarding the hygiene of menstruation.
It should also be emphasized that the first
menstrual period is a sign post on the road to
maturity. She must be made to realise that though
she may look like a little girl, she is a woman
because her body is old enough to bear children
and that menstruation is the outer evidence of the
reproductive cycle. Failure of the adolescent to
realise the implications of and potential dangers
of sex can lead to tragedy. Hence sex education
should come naturally and perceived through
childhood. Any questions they may ask or the
doubts they get, should be answered simply but
truthfully. Mothers at home and teachers can play
a great part in this and indeed sex education
should also be a part of general education of the
child. Children are never too young to learn
something about sex and they are especially
curious about the matters of sex education from a
quite young age. If sex education is not imparted,
pit-falls can occur due to innocence and
ignorance of sex, while others many suffer from
over emphasis of sex education. The uninhibited
adolescent who thinks she knows everything may
also succumb because she is not mature and
cannot understand the implications of sex. At any
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rate it should be emphasized that it is the girls
who always suffer from uninhibited and
unprotected sex and they must be imparted the
knowledge of all the pitfalls which attend
unbridled urges.
Apart from the above some girls experience
severe dysmenorrhoea because their education
and outlook is faulty. The expectation of pain is
fostered by over-anxious parents and by
curtailment of normal activities during
menstruation. Later after marriage the person can
suffer from vaginismus causing severe spasm of
the sphincter vagina and thus the lower vagina is
practically closed and is the cause of
dyspareunia. This often is also accompanied by
frigidity. One of the factors in the causation of
vaginismus and frigidity is faulty sex education.
Other factors include ignorance, initial painful and
clumsy attempt at coitus (an unfortunate
experience such as criminal assault), or guilty
conscience over premarital sex experience, feat
of pregnancy and child birth and dread of veneral
diseases. Most often in all these nothing more
than sex education of both the partners is all that
is necessary.
Unfortunately today sex education is being
equated to what is shown in the movies and films
and young girls are being lured to imitate the
same not knowing the future consequences.
Many indulge in sex not realising that if they miss
the period it is probable that they are pregnant
and do not consult the gynaecologist till it is too
late. Others take care by taking oral contraceptive
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pills. Many more are undergoing medical
termination of pregnancy. It is appalling to see the
number of unmarried girls undergoing MTP the
number is increasing day by day.
What is essential today is:
Sex education in schools should be
undertaken with great care. Stress should be laid
on emotional, philosophic and teleological aspect
of sex.
Nature intends the sex act to be sublime and
instrumental in keeping two human beings bound
together and for the continuation of species, and
this more laudable objective seems to have
escaped the attention of the educators.
Momentary sex without emotional background is
anti-social and against nature. Studies in the west
have clearly shown long term ill effects of the
modern culture there, resulting in divorce, suicide
and drug addiction amongst youth. It is the duly of
the Government, the parents and the teachers to
inculcate our ethical values in sex education in
schools.
FAMILY PLANNING
Primary health care reaching the whole
population is central to the strategy for Health For All
and family planning is an essential element of this
Primary health care.
- W.H.O.
The extensive differences that exist in cultural,
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religious and personal attitudes as well as health and
socio-economic status, tend to reinforce the need for
as wide a range of fertility control methods as is
technologically possible. Such measures must be
personally and culturally acceptable, convenient to
use, safe, inexpensive, easy to distribute and store,
and sufficient in number to encompass the change of
life situations that may be experienced by the couple
as the partners progress in their respective years.
Despite the numerous advances in family
planning that have taken place in the last two or
three decades, the need for highly effective and
acceptable method of contraception still exists.
There is no method which is 100% effective,
completely reversible, totally acceptable and
absolutely free from side effects. However
unfortunately, contraception and sterilization are
subjects that have generated lot of controversy.
What is written here is designed only for the clinical
gynaecologist and obstetrician but not for others like
sociologists, moralists and the like.
The Indian programme has relied heavily on
sterilisation until now as a measure of family
planning. This approach is unlikely to achieve the
desired objective in population growth. It seems that
effective spacing methods should receive great
emphasis in future and every couple must make an
informed choice as what they should choose at
different times i.e. for postponing the first child after
marriage, to space the second birth, limitation by a
reversible method for 5-8 yrs and then perhaps
sterilization.
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Regarding postponing the first childbirth after
marriage a caution has to be given. If the couple
gets married late even. If the couple gets married
late even if they come for the advice for
postoponement of first child birth-out duty is to
advise them to have the baby early. As one knows
the fertility rate drops with the advance in age and
conditions like endometriosis and fibroids etc are
common in these women. Even in young couples
better to advice them some sort of barrier
contraceptive like a condom etc as they do not
disturb the normal menstrual cycle; even if they fail
and the couple conceives it is good for them. Also
one should think twice before one prescribes the oral
contraceptives in women who have irregular and
scanty periods. While the pills produce a regular
cycle, the bleeding at the time of the period becomes
less and scanty and these women may develop the
so called post pill amenorrhoea. They may even
blame the doctor for her not becoming pregnant
even though the cause can be some thing else. Oral
contraceptives can be prescribed for short periods in
those having heavy periods and dysmenorrhoea and
in these women they have definitely a beneficial
effect; even here there is much to be said for the
motto dont delay the first as an axiom for al newly
married couples as today very early marriages are
rare (except in one or two communities). If the
couple conceive, they not only proved to be fertile
but it is a source of great satisfaction and happiness
in parents and in-laws. It is also equally important
that loop is strongly contra-indicated and should
never be prescribed in women seeking contraception
before the first child birth. In which cases it may
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produce PID (Pelvic Inflammatory Disease), no one
can predict and the tubes can get blocked in these
cases and the couple remain infertile later.
Regarding the second one i.e. spacing the
second birth and limitation by a reversible method by
5-8 yrs, here intra-uterine device is ideal as it is a
one time procedure. The patient can be motivated
well and persuaded by dispelling her apprehension
regarding the side effects. It is also seen that all pills
are not the same and once a particular patient has
decided to use a contraceptive pill, the physician has
to advice them on the correct choice of pill suitable
for that particular individual. And of course a careful
follow up of these patients and advising them
correctly on the various side effects they produce is
equally important.
Much controversy dogs regarding the use of
injectables i.e long action steroid preparations. They
are attractive both to the physician and the patient
because of the convenience of use (as injectables
like Depomedroxy progesterone acetate are given
once in 2-3 months). Of course they cannot be self
administered, treatment cannot be reversed in a very
short time, often accompanied by irregular bleeding,
as well as a long and a variable delay in return to
fertility.
Subdermal implants containing progestins are
being tried. The advantage is that implants can
deliver contraceptive levels of progestin for upto five
years or more. However apart from the side effect of
irregular bleeding, as the implants have a limited
surface area six or more rods must be used to
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achieve appropriate blood levels of the hormones.
This means several unacceptable surgical sites for
the users.
For science to progress and in trying to find out
what is the best and ideal and easily acceptable
contraceptive such trials should go on as in the
case of indictable steroid preparations and
intradermal implants. Yet it is only ethical to explain
to the patients and convince them before embarking
on these trials. In countries where these are being
used people have been happy. Howe the Indian
population will take them one has to wait and watch.
Another option in fertility control is to use drugs
which act as competitive inhibitors of progesterone,
termed as Morning After Pill. Pregnancy can be
prevented by giving large doses of oestrogens within
72 hrs of unprotected coitus in the mid-cycle
especially when pregnancy is not desired. In spite of
intense side effects like nausea and vomiting which
are of transitory nature the treatment proved useful
in 99% of cases.
Medicated intravaginal rings and intracervical
pessaries are being tried and oestrogens are added
to progestin to circumvent break-through bleeding.
Yet again in the long term the effect of direct release
of oestrogen on vaginal mucosa and cervix is not
known.
Much is in vogue regarding the usefulness of
non-steroidal contraceptives. Though quite
encouraging results have been published, it is too
early to assess their potential for general
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acceptance.
Regarding sterilization upon which the entire
programme is depending, there is no doubt that post
partum tubectomy is ideal and simple. It is easy to
approach the tubes with a small incision as the
fundus of the uterus is high up in the abdomen. It is
good in those women having three or more children.
Many young couple are requesting today for the
sterilization operation even after only one child,
basing their argument that to have one more child is
a luxury that they cannot afford in these days of
escalating cost of living. In these one has to think
twice before doing tubectomy, in the immediate post
partum period as it is not a reversible method. It is
better to advice the couple to use either barrier
method or pill or loop till the children grow and
develop resistance and do an interval sterilization by
doing tubal ligation by the laparoscopic method. It is
not uncommon to hear that the only child of a couple
either died as a result of accident or disease.
None is against the target oriented and mass
sterilization operations done in camps. It looks as
though to tell the public that so many operations are
being done by various agencies organizing them
(Governmental or voluntary) and for the operating
surgeons (each one of them) to say and claim to
have done so many per day and one vying with the
other for the shortest time taken for each case.
Every one would like to compliment them. But in the
bargain, overconfidence and the quick turnover led
to the round ligament being cauterized or clipped
and thus resulting in many failures. Also in these
camps the patients are not being screened properly
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as to whether they are fit for the operation or not,
adequate sterilization safeguards are not adopted
and also the patients are not properly looked after in
the post-operative period. No wonder quite a few
post tubectomy deaths are still reported even now
and imagine what will happen to the family and the
fate of the kids who become motherless and nobody
will be there to look after them. It is all the more
tragic as usually these patients are very young and
healthy and have no other complaints and the
operation is just done only for family planning. What
is more important today is not only the number
operated in the camps but also the quality of service
given and the care of the patients taken.
Occasionally the question arises as to the role
of hysterectomy as a family planning procedure. I
cannot add anything more then what is written in
Wiliams Obstetrics 1993 regarding this for a woman
who desires no more children hysterectomy has
many theoretical advantages. The only known
potential of the uterus, other than child bearing is to
harbour disease. In the absence of uterine or pelvic
disease, hysterectomy for sterilization at the time of
Caesarean delivery, early in puerperium or even
remote from pregnancy is difficult to justify. Mortality
rates from hysterectomy vary from 5-
25/10000 in women in the age group of 35-44 (Wing
& Colleagues 1985). With Caesarean hysterectomy
blood loss nearly always is greater than Caesarean
plus tubal sterilization leading to much more frequent
use of transfusions and their sequelae. Urinary tract
injury is also appreciably more common.
As such, hysterectomy as a family planning
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procedure is not ethical or moral and one should not
do it. However the question is asked whether
hysterectomy can be done in mentally retarded
patients who though their chronological age is 20 yrs
or more yet they have a mental age of three or four
years. They cannot look after themselves in day to-
day living and cannot observe menstrual hygiene. In
such cases if the parents request the obstetrician
and gynaecologist, and the psychiatrist opines
regarding the mental status of the patient,
hysterectomy can be done. Here the obstetrician or
the gynaecologist is only helping the parents to look
after their child better. Of course, it is not done as a
family planning procedure but as health measure
giving due consideration to the mental of the patient.
Lastly it is very disturbing to note that many of
our people prefer to have an MTP rather than using
any one of the family planning procedures. It is very
sad to observed the number of terminations done.
MTP is advocated as a health measure but not as a
family planning measure. In the interest of the
mothers health concurrent contraception should be
advised/insisted ethically and morally by the
obstetrician and gynaecologist whenever he does an
MTP.
Vasectomy in the male at one time was a
popular method. It is a matter of concern that there is
a decline in the number of men opting for vasectomy
today. Is it not more ethical to persuade men and
make them accept this procedure which is simple
and can be done as an out patient procedure under
local anaesthesia. But men still have a lingering
feeling and doubt, that their virility gets diminished
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after the operation and it is indeed a great task
convincing them and dispelling their apprehension
and make them agree for this simple and harmless
procedure.
Since many years trials are going on regarding
the possible role of use of vaccine against HCG
(Human Chorionic Gonadotrophic hormone) as a
contraceptive measure. HCG is very essential for the
induction of ovulation (as it has the same action as
LH (luteinising hormone) and also for the survival of
corpus luteum and production of progesterone which
is very essential for continuation of pregnancy.
Vaccine against CG theoretically should be an ideal
method for conception control. Trials in India showed
very promising results and control of conception was
achieved. Results from abroad were not encouraging
and they also pointed out that because of the cross
reaction with LH in the body some possible long term
side effects may occur. Even though there is a lot of
apprehension regarding the use of vaccine, yet it is
only fair to continue the trials in well-informed
volunteers prepared for the trials and such trials
cannot be called unethical.
Family planning should become a way of life for
all of us. Importance of family planning and family
welfare should be stressed and ingrained in
everyones mind today. There is no salvation for our
country unless the population growth is checked. It is
the ethical and the moral duty of everyone in our
country (whatever may be the sphere or walk of life,
to observe and propagate family planning. However
it must be said that family planning and integrated
child health programme should and must go hand in
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hand if one wants to achieve the objective meant for
i.e. HEALTH FOR ALL.
There have been several surveys around the
world indicating that female education achieves two
important goals increasing the age of marriage;
enhancing employment opportunities thus raising
their economic status. In short, female education is
the best contraceptive and is the master key to the
problem of population growth. The above is amply
illustrated in the highly literate states of India like
Kerala, Maharashtra and Tamil Nadu, which have a
low birth rate.
At the end I cant but resist to mention what
Late Dr VN Shirodhar in his characteristic humorous
way regarding family planning giving the example of
the three monkeys See not evil, hear not evil, speak
not evil and the last one make not evil.
N.B.: There was a big hue and cry regarding
the hysterectomy operations performed on young
mentally retarded girls. No text book of gynaecology
mentions that hysterectomy should be done in such
cases. I have already explained there is nothing
unethical in doing hysterectomy to such unfortunate
ones provided the psychiatrist approves and when
the parents come and request for the same. The
above operations should be done in the routine
course as it is the prime duty of everyone to help
these unfortunate girls. It is written in our scriptures
that while trying to help somebody, even the left
hand should not know what the right hand is doing
and much help can be given quietly without any
fanfare etc.
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THE WOMB - A SAGA OF ECSTASY AND
SACRIFICE
Situated nicely in the female pelvis the womb or
uterus (along with its intimate friends the fallopian
bubes and the ovaries) enjoys a special status. It is
supported by two broad ligaments and round
ligaments which attach it to the lateral pelvic wall and
also be the muscle levator ani and the special
structures called retinacula which keep it in its
position.
As the child grows the womb along with the
obaries grows so as to be ready for the purpose for
which they are created (to play a great part in
reproduction); so that this progeny (parampara) goes
on and on and the world consists of live human-
beings. If the uterus is not developed or absent no
pregnancy occurs. Mother nature has designated the
uterus as the most privileged organ to carry the
pregnancy to term.
To achieve the above goal, from the time of
puberty the uterus cooperates with the ovaries and
also with the pituitary and hypothalamus in the brain
forms what is called Hypothalamus-pituitary-
ovarian-uterine axis. Every month the lining
membrane of the uterus ie endometrium reacts to
the hormones produced by the ovary produces a
nice bed for the fertilized ovum to come and get
implanted. However when the ovum is not fertilized
the uterus gets disheartened and weeps and
produces bleeding called menstruation. Women
menstruate because they do not conceive. Every
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month this goes on and on till the woman gets
married and plans to conceive.
After marriage along with the cervix and vagina
it helps to produce secretions, relaxes and
stretches so that the couple can enjoy fully the
marital bliss. The uterus is so obsessed in its desire
to get and beget children, that when it is deprived of
pregnancies it consoles itself with myomas or
fibroids (tumours of the uterus). Prof Jeffcoate puts
it, fibroids are the result of virtue and babies are the
fruit of sin.. He has further added, Deferment of
pregnancy encourages fibroids and fibroids then
discourage pregnancy.
When once conception occurs and the fertilized
ovum gets implanted in the endometrium, the uterus
gears up to take the pregnancy to full term of 40
weeks (9 months and 7 days). To that extent it
enlarges and distends with each month of
pregnancy, comes out of the pelvic cavity so that the
foetus has enough space to move about. In the
process the musculature of the uterus becomes soft
and elastic losing its firmness; the blood vessels
become engorged giving more blood supply to the
growing uterus so that the baby gets all
nourishment for its growth and development. The
mouth of the womb ie cervix is a closed organ with
its muscle and fibrous tissue having a grip and
provide tight security so that pregnancy does not get
terminated prematurely.
When the patient goes into labour, the uterus
with its musculature rearranges and acts in such a
way that the uterus develops in two segments for the
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descent and for accommodating the foetus. The
action of the uterus is so synchronous that the upper
segment contracts, pushes the baby down and the
lower segment expands to accommodate the baby
and the cervix loses its identity upper part, internal
os becomes one with the uterus above and the lower
part, external os dilates fully so that the uterus cervix
and vagina form what is called parturient canal for
the safe passage of the foetus from inside the
uterine cavity to the outside world the shortest
journey (a human being takes in life) by the most
vulnerable journey in life, because on the safe
delivery lies the future well being of the foetus.
AS soon as the labour is over, the uterus and
its musculature contract in such a way that no
danger occurs to the mother from the bleeding that
follows after delivery. In a short time of two months
the uterus gets involuted and become small and
comes back to the original state. No organ in the
whole body is so unique in its various diverse
functions such as helping a married life, protecting
the child and safely delivering a healthy child for the
happiness of the couple and one and all.
While the ovarian hormone oestrogen is
responsible for the feminity of the women like soft
skin, contours of the body, development of the
breasts, growth of the hair on the head etc the uterus
is also given an equal share in all these. People
have a conception that everything the women has ie
physical body as well as mental attributes are due to
the uterus. Their anger, the change of mood, the
temperament, the vanity, jealousy, pride and
intolerance for other women are thought to be
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originated because of the uterus. It is often said in
the Army that the wife of the colonel behaves like a
brigadier. Even so in civil life the same thing
happens in the behaviour of the women with regard
to their attitude towards subordinate staff. AS seen in
the vagaries of the uterine contractions during
labour, all these are attributed to the unpredictable
nature of women. Anyone having such attributes and
behaviour are called hysterical. (Hysteria means
uterus).
Frailty thy name is woman says Shakespeare
in Hamlet. One wonders if vanity also goes with
frailty. It is a common observation that most women
put their plait in front (even if it is small like a pony-
tail). Does it also indicate vanity and ego which
sustain them in spite of the odds and vicissitudes
they have to go through in life. Perhaps, their very
strength lies in their frailty.
While giving happiness to the lady, none
realizes what troubles the uterus has to undergo; the
trauma and the torture it has to bear. If the periods
do not occure (amenorrhoea), if they are painful
(dysmenorrhoea) and the periods are profuse
(menorrhagia) in all these the fault is somewhere,
yet the uterus is blamed and the operation of D&C
(Dilatation of cervix & curettage) is done on the
uterus, rightly or wrongly. MTP permissible under
law, has become the fashion of the day and
repeated curettings are done. While so doing, the
cervix also gets traumatized. Occasionally a drastic
curettage can cause intrauterine adhesions and
periods may stop. The uterus and the cervix are the
targets of infection by sexually transmitted diseases
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which, sometimes produce severe transmitted
diseases which, sometimes produce severe damage
to the entire female generative tract.
Certain amount of trauma occurs to the cervix
even after normal vaginal delivery more so after
operative procedures. All the supports of the uterus
become slack and their tone becomes less.
Uterus normally requires a rest period to recoup
after delivery. If the pregnancies are not spaced and
the tone of the muscles is not restored it may lead to
descent of the uterus ie prolapse.
The uterus also bears the insults inflicted upon
it. In case of premature deliveries a stitch is put on
cervix. If the labour is prolonged, operative delivery
like forceps application can cause trauma to the
uterus and cervix. Sometimes the baby is delivered
by caesarean section with an incision in lower
uterine segment. If timely help is not rendered uterus
may even rupture. One if a caesarean is done,
because of the danger of the rupture of the scar
repeat caesarean is performed.
If the patient is having backache and white
discharge and if the cervix is infected or an erosion
is present, in the name of treatment, the cervix is
burnt with electric or diathermy cautery. At times
cone of the cervix is removed.
In patients who are infertile, if per chance the
uterus is backward in position (retroverted uterus),
operation is done to make it anteverted. It has to
bear with patience procedures like salpingogram or
even hysteroscopy let alone endometrial biopsy or
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curettage done as investigative procedures. Surgical
operations like myomectomy (removal of fibroid),
and plastic operations for correction of uterine and
tubal anomalies are done all for in the name of
treatment of infertility.
After delivery in the name of family planning
loop is introdueced in the cavity of the uterus.
Uterus does not like it yet it accepts it. The loop in
turn causes local disturbances and produces more
bleeding during periods and also occasionally
causes infection of the genital tract.
After delivery in the name of family planning
loop is introduced in the cavity of the uterus. Uterus
does not like it yet it accepts it. The loop in turn
causes local disturbances and produces more
bleeding during periods and also occasional causes
infection of the genital tract.
As the woman becomes older and comes to the
age of 35 to 40 years the stress and strain of life
today is such that they get premenstrual tension,
oedema, heaviness in the breasts and irritability etc
and the uterus is blamed for these. After tubectomy
operation done as part of family planning procedure
if there is a abdominal pain the operation as well
as the uterus are blamed. Lower abdominal pain can
be due to problems in the gastro-intestinal or urinary
tract yet the fault is ascribed to the uterus. Irregular
profuse and prolonged bleeding occurs in some
women at the perimenopausal age. The uterus is
only slightly bulky yet though the cause is hormonal
the brunt fall s on the uterus.
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In both the above, if there are two children or
more in the family the uterus is thought to have
served its purpose for which it is created and is
discarded and a hysterectomy is done in many a
case in the name of treating the patient as well as in
the prevention of development of cancer of the
uterus. If there is an erosion on the cervix the uterus
is removed in the name of possible development of
cancer of the mouth of the womb ie cervix.
Many a times the uterus is sacrificed for no
reason or for a very trivial one. The uterus is made
the scapegoat for all women troubles. If she is
having constant headache, gases, uneasiness and
pain in the lower abdomen, white discharge even if it
is due to vaginal infection or constant backache-in all
these the uterus is at fault. Removal of the uterus
has become a panacea in the treatment for all
women troubles. Even in the modern technique of
laparoscopic hysterectomy uterus was pierced and
tramatized first before it was removed. My Guru Dr
BN Purandare, a master in vaginal surgery used to
remove the uterus through the vaginal route in a very
short time without any scar. I cannot just understand
why we should traumatize it while removal. However
removal of the uterus has become a status symbol in
women. Women who got operated feel that they
belong to a different and higher class than others! In
most of the cases where hysterectomy is done even
for bleeding cases the pathological report often
shows the uterus, endometrium and the cervix
normal.
Uterus, more than any organ in the human body
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except, perhaps vermiform appendix and tonsil is
most susceptible for operative removal for no
justifiable reason clinically or pathologically. The
number of hysterectomies that are being performed
now are colossal. In some parts of our country it is
often rare to meet a woman over thirty with her
uterus in its place! It should not be that while
teaching the students regarding the indications for
hysterectomy, presence of the uterus as an
indication and absence of the uterus as a contra-
indication.
Whenever I think of the role of the uterus, I am
reminded of the story of a tree and a young boy
narrated by Osho Rajneesh in one of his discourses.
The tree loved the boy so much that it allowed him to
play on its branches and give fruit to him. Later when
the boy, now a man, was in need of money, it asked
him to pluck its fruit and sell them. When he wanted
to build a house, the tree asked him to cut its
branches and use the wood for the roof. Later, the
tree even allowed him to cut its trunk to make a boat
so that the man could go to far off places to earn. In
the bargain the tree was reduced to a small trunk
and yet, it was always thinking of the safety and
welfare of the man. The tree sacrified everything of
itself for the man and did not take anything in return.
This tree is like to proverbial Kalpavriksha in our
mythology and like it, the uterus too wants to give
and does not want to take and a even prepared for
any sacrifice including its own removal if that be in
the interest and the welfare of the person. What
applied to the uterus by and large applies to the
women in general and mothers in particular. Their
role in day-to-day life is one of Nishkam Karmayoga.
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They only given and do not take. They have their
periods of ecstasy and periods of suffering and
sacrifice.
Nishkam Karmayoga indeed gives all your
duties an essence of sacrifice, be it a success or a
failure! Everything is devotedly dedicated to Him!
That is how the uterus also is functioning in the
cause of Humanity. Like a sthitaprajnya, it continues
to function regardless of success of pregnancy or
sex of foetus!
THE OBSTETRICIAN & GYNAECOLOGIST :
TRIMURTI OR DATTATREYA
Obstetrics and Gynaecology is a fascinating
innovative and progressive branch of medicine
encompassing two acute specialities and combining
medicine and surgery with the excitement of
midwifery.
In no other branch of medicine one gets the
chance to play a unique triple role except
inobstetrics and gynaecology. In assisted
reproduction in cases of infertility he plays the role of
Lord Brahma (Creator), in helping pregnant women
to pass through safe pregnancy and labour he plays
the role of Lord Vishnu(protector) and by terminating
pregnancy in cases of congenital foetal anomalies or
even in medical termination of pregnancy or
occasionally to save mothers in case of obstructed
labour he may have to do destruction of foetus and
thus playing the role of Lord Shiva (Destroyer). In
that way he is thrice blessed and indeed he is three
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in one TRIMURTI or DATTATREYA.
The transcendent objective of obstetrics is that
every pregnancy be wanted, and that it culminate in
a healthy mother and a healthy baby. Obstertircs
strives to minimize the number of women and infants
who die as a result of the reproductive process or
who are left physically, intellectually or emotionally
injured from the process. Obstetrics is further
concerned with the number and spacing of children
so that both mother and offspring, indeed all the
family, may enjoy optimal physical and emotional
well-being. Finally, obstetric strives to analyze and
influence the social factors that impinge on
reproductive efficiency.
Williams Obstetrics 19
th
edition 1993
With the advent of ultrasound, more than ever
before the present day obstetrician is able to look for
and diagnose congenital anomalies of the foetus,
intra-uterine growth retardation, placenta praevia etc
and initiate appropriate line of treatment.
Gone are the days when masterly inactivity and
wait and watch policy of tincture of time; they are
now replaced by active management of labour. With
the help of Doppler (foetal monitor() he can
recognize foetal distress early, by careful
examination and follow up with help of partograms,
will be able to detect dysfunctional labour, dilatation
of cervix and descent of the presenting part, and can
ensure the treatment at the right time. The problem
today is to maintain a balanced perspective towards
vaginal and abdominal route of delivery in
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complicated cases. Obstetrician must never assume
that parturition is normal until after safe delivery. One
should not be led away by the request for speedy
delivery. The obstetrician is likened to a
mridangam (drum), which is beaten on both the
sides. He can be blamed for too early or to late
intervention. Only be experience and a balanced
consideration of all circumstances will the
obstetrician learn how to act in a particular case, and
each case is a specific problem. It would be a sad
day for prospective mothers if caesarean sections
were to run prior and indiscriminately employed for
complications which can as well be treated by
ordinary vaginal procedures.
In obstetric emergencies, where one has to
deal with very poor risk cases (for example cases of
acute rupture of an ectopic gestation, uncontrolled
eclamptic convulsions, severe cases of antepartum
haemorrhage or cases of rupture of uterus as a
result of obstructed labour, severe post-partum
haemorrhage after labour or even trying to deliver a
breech baby, - the obstetrician has to walk on a
razors edge (between devil on one side and deep
sea on the other) and take a mature judgement in
these cases. In all such case the attitude of the
obstetrician should be one of calm, cool and
collected like a cucumber and he should not get
perturbed and should do everything possible to save
the patients. Whatever be the outcome in a particular
case his/her mind should be clear. I am remined of
what I read as a student Polonius advised his son
(in Shakespeares Hamlet) The above all to thine
own self be true. And it must follow as the night the
day. Thou canst not then be false to any man.
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Everything he or she does should be perfect
and conform to the situation. Even if one has to
apply forceps either for prolonged second stage of
labour or for foetal distress, I always kept in my mind
what late Prof FJ Brown (a great teacher) advised
keeping the blades in hand the obstetrician should
put the question to himself whether all conditions are
satisfied for safe application. The two blades of the
forceps are meant one for the foetal distress and one
for maternal distress. I wish to add that one is for
foetal health and the other for maternal health. For
the preservation of safe motherhood, it is also the
duty of the obstetrician to train and arrange courses
for birth attendants, midwifes and MCH doctors at
the corresponding level of care in the prevention and
management of the causes of maternal death. He
should also supervise their work and take overall
responsibility with regard to the obstetric care of the
patients.
Let alone this because of things as they stand
today, the tendency is to practice defensive
medicine. Unfortunately the whole medical
profession is caught up in the web of defensive
medicine, which is its own creation. It is painful to
see the number of needless tests or investigations
done for any case today and the attitude of taking no
risk is one of the main reasons for the increasing
number of caesarean sections done today and
trainees in obstetrics are deprived of the skilful art of
obstetric manoeuvres. When I was a house surgeon
a bell was rung whenever a caesarean section was
done so that every doctor could come and see it.
Days are not far off when a similar bell would be
rung in future when a normal delivery is going to take
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place. It is the duty of the teaching faculty of our
speciality to uphold the traditions on one side and
learn the newer methods and techniques on the
other side and hand over them to the younger
generations. It is also equally important that the
teaching and treating the patients should go
together. It is unethical to teach one thing and not
follow the same in treating the patients. There is an
old proverb Yatha Raja, Tatha Praja (as the King so
are the People).
Days have come when all practising
obstetricians should get well acquainted and have
thorough training in the wide spectrum of non-
invasive diagnostic gadgets, especially sonography
(including trans-vaginal method. This helps in a long
way not only in the prophylaxis but also in the
detection of various obstetric and gynaecological
conditions at a very early stage.
Also, it is imperative that those who intend to
specialise in endoscopic surgery should get
thorough training in all respects in well recognized
Institutes where there are updated facilities including
trained surgeons anaesthetists and nursing
personnel. This is all the more applicable to teaching
staff in all medical colleges and hospitals who in turn
should impart training in their respective institutes. It
is gratifying to note that so many workshops are
being arranged for giving training in endoscopic
surgery. However, it is only ethical that there should
be set guidelines regarding the type of surgical
procedure to be performed endoscopically and the
expertise level to be required of those who would like
to practice them. Patient selection and surgeons
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own assessment of his surgical skill and critical
approach are very important. It is only then that this
type of qualified medical care will be available to a
vast majority of the people which in present day
seems to be quite inaccessible.
By properly giving the appropriate contraceptive
advise and advising the patient to take post natal
exercises and good nutrition, the obstetrician
gynaecologist can maintain and preserve maternal
health after delivery.
In the present day context the word
gynaecology conveys no conception of disease and
hence no more disease of women of diseases of
female generative tract. The word Logas is
interpreted as lore. Hence gynaecology is the lore of
women and understanding, a far as possible, of
their psychological, physical and functional
phenomena from cradle to grave, but specifically of
the delicately balanced epochs of puberty,
pregnancy and menopause. To this must
unfortunately be added their pathology, but this
should not be permitted to dominate the problem
picture of womens whole life and well-being. In this
respect the obstetrician gynaecologist with proper
understanding of their problems and by giving
appropriate treatment with kindness sympathy and
affection, can to a great extent alleviate their
problems. Thus the obstetrician gynaecologist can
contribute positively for maintenance of maternal
health. All women whatever their age may be, are
mothers some are mothers of the future, some
present and others continue to be mothers. No
consideration of maternal health is complete without
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an integrated child health programme and only the
combined health of both represents the health of the
nation.
Every surgical operation is a delicately
conducted experiment in physiology with the
greatest solicitude of the welfare of the patient.
- J. Jefferson, Neurosurgeon.
EPILOGUE
A philosopher, when once asked as to what is
the most important event that is occurring in the
world, his immediate reply was Change and that
change is the essential phenomenon that occurs at
all times in every field. Old order old ideas are
discarded and replaced by new ones.
Even in the field of medicine new diagnostic
tools have been invented, concepts regarding
causation of diseases changed, let alone thinking
and management. We are entering an era where
robots are going to play a very important role in
future.
Amongst all these changes and in new
innovations, there is only One Person, The Lord or
Paramatma or Brahman, in this universe who has no
change, no birth nor death, Who is beyond time and
space and controls the Maya or illusion and Who is
all-pervading, and Who has taken seat in the hearts
of every being and along with Prakriti is responsible
for the occurrence of every thing including the very
existence of this universe.
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A review of what has been written only points
out that without His Divine Dispensation and Grace,
conception and pregnancies do not occur. For the
preservation and welfare of mankind (so as to
protect and prevent the foetus in utero being
immunologically rejected, the Lord does not mind
violating His own laws if that is essential for the
continuation of human race. Lord always thinks of
Lokakalyanam (universal welfare) and while doing so
He taught the world the importance of two powerful
weapons Tolerance and Acceptance.
What determines the future sex of a baby is
not known nor does one know what exactly is the
cause of onset of labour. This only shows that man
has no control on anything in life. One cannot select
their future parents, let alone the place and time of
delivery and equally important the time and mode of
death. All these are in the hands of the Lord
Almighty and all one should do is to prayer, puja,
namasmarana, mediation and good deeds in this life
which, to some extent, helpto get the grace and
blessings of the Lord.
Prakriti or Shakti or the energy plays an equally
important role in the survival and continuation of the
human race. Pregnancy is physiological and mother
nature does everything for its safety. Yet stree or
mother which represents Prakriti has to bear and
forbear throughout; at times the period can be trying
on the pat of the mother and requires lot of patience
and perseverance. Pregnant mother is the custodian
of the future health of the nation and mother
sacrifices everything for the welfare of the family.
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Mothers influence on the foetus starts from the
time of conception. Her food, thoughts, type of books
she reads and the music she listens to and the
atmoshphere at home all these have a great
influence on the foetus.
Labour is hard work and painful, yet mother
takes it as a duty and bears all the kashta; ie. hard
work to achieve and fulfil the goal of having
contributed to the progeny of the family.
Of all the events that occur in the world today
certainly one cannot but admire the various
phenomena occurring during labour. A co-ordinated
effort on the part of uterine contractions on one side,
the cooperation and erasement of ego on the part of
cervix in effacement and dilatation as well as the
give of the birth canal and the part played by the
foetus all contribute in successful termination of
labour. Certainly one cannot but admire (sometimes
with awe and anxiety and many a time with pleasure)
what a wonderful phenomenon childbirth is? It is
amazing to observe the movements of foetus during
the process of the shortest but the arduous journey
in its life from inside the uterine cavity to the outside
world. In that process the foetus knows what is good
and adapts an attitude of flexion which is essential
for safe delivery. While so doing the o\foetus has
given the world a golden rule to be observed by
everyone at all times i.e the attitude of flexion which
depicts the qualities of vinayam, humility, respect to
elders and last but not the least to erase ones ego.
Non observance of this golden rule leads one to
become proud and arrogant which ultimately end in
remorse and disappointment.
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The baby after birth cries and in that first cry
lies the whole of Vedanta. Baby laments for being
born in this world as it is fully aware of the hardships
that lie ahead; exhorts everyone to do Ajapa-Japa;
i.e. (spontaneous japa done during breathing)
Soham-saying that the ultimate Paramartha in life is
to know THAT THOU ART; and at the same time
pleads the Lord to salvage from the samsara of
births and deaths.
While one learns all this and more from
obstetrics, all the gynaecological conditions reflect
and point out the various precepts handed over by
elders from time immemorial.
Similarly too much of anything a in over-eating
or under-eating is not good for health. Both obesity
and starvation cause pathological amenorrhoea.
Continuous medication without supervision in some
cases is bad for health as exemplified in continuous
taking of oestrogens for hormone replacement
therapy may lead to carcinoma of the endometrium.
Two people can be close, but occasionally one
may have to suffer because of too much closeness
as the urinary tract suffers being too close to the
genital tract.
Everyone in life expects to be respected and
treated well. If such a person is made to undergo
trauma and insult he or she will naturally revolt as
it occurs in case of bladder during child birth and
ureter in gynaecological surgery.
For peace to prevail countries should respect
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each others territorial integrity; same applies
also to states, cities and even villages. Unauthorized
occupation or fighting for land or estate or property is
a common observation. In one and the same family,
let alone between two neighbours, fights go on for
the sake of property. Such scenes can lead to
disorders or at times insurgency, as typified mostly in
endometriosis and carcinoma of the cervix.
Coordinated action of everyone is essential for
smooth functioning in an organisation. If someone
who is good initially takes to his head and tries to
dominate others, he can become pigheaded and
erratic, he may pose problem for the organisation
itself. Oestrogens are the hormones of the female,
yet hyperoestrinism (if not counterchecked by
progesterone) leads to conditions like anovulation,
dysfunctional bleeding, fibroids, endometriosis and
even carcinoma of the body of the uterus and of the
breast.
Even temperament in sukha or dukhkha is
advocated. Adjustment to the changed
circumstances and living life with contentment is a
boon (santushtam satatam yogi). If one does not
have these qualities or virtues, they make their life
miserable as applied to cases of premenstrual
tension syndrome and menopause.
All these singly or combined are manifest in
various gynaecological problems described.
What is more, the discipline of obstetrics and
gynaecology stresses the importance of the ethical
and the moral values to be observed in management
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and treatment of various conditions. It also stresses
that the obstetricians attitude in the management of
labour and emergencies, should be one of kindness,
compassion and sympathy as his decisions may
have to vary and confirm moment to moment living,
but always keeping in mind that his essential duty
and role is for the preservation of safe motherhood.
Over-confidence on one hand and delay and
decision on the other hand have no role whatsoever.
I have often wondered as what it is that this
discipline has not taught and stressed about various
moral aspects in life? Probably Bhagwan in His
Sankalpa for the good of mankind has put al the
precepts in this branch of medicine and given His
Divine Message. More important than anything else,
the stress is laid one the Nishkam Karmayoga
(Karma done for dutys sake without expecting any
reward or fruits of it) on the part of Matru stree; and
is all the more great because the karma is done with
the spirit of tyaga, sacrifice, benediction and love
which makes Motehrhood the greatest virtue at all
times.
Janani janmabhumishcha swargadapi gareeyasi
(Mother & Motherland are regarded like Heaven)
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