Saturday, June 30, 2012

Do you really wish a vaginal delivery??

Most of my posts are based on real life experiences and this post is one such post.I have noticed that it is in 'vogue' to have vaginal delivery.Why did I use the word 'Vogue'?After all I am supposed to be a proponent of vaginal delivery and I am sure many of you would not like me to use ' in Vogue' with something as natural as a vaginal delivery.
I have few experiences to share.It is not to crib about anyone or anything.It is just to help the pregnant women who are reading this blog to prepare them better for 'what to expect when you are in actual labour'.
First of all ask yourself,why do you wish to have a vaginal delivery?Is it so because you genuinely wish to have it or just because your friend had it?In the middle of this month I had at 9 Pregnant ladies within 24 hours who were in labour ,wished a vaginal delivery badly but didn't wish to get even a vaginal examination done.Both the Ladies and the family members wished a vaginal delivery but wished me to speed up the whole labour and delivery process.A mention of word caesarean to get it done quickly evoked very strong reactions from them.Strangely there is so many myths about epidural analgesia.At 32 weeks I invariably talk about epidural analgesia to all my pregnant patients with its pros and cons.But somehow when in labour they are still very much anti epidural.As the labour pain reaches it's cresendo,they want it but husband's,moms and mom  in laws are not agreeable to it
Just ask yourself.......are you one of these ladies.Then sorry vaginal delivery is not for you.Doctors are there to help you but can't speed up the labour or take the complete discomfort of Labour.There is nothing romantic about a vaginal delivery.If you have any fears regarding vaginal delivery discuss with your doctor.have realistic expectations from doctors.Don't expect that as the doctor is pro vaginal delivery you surely will have a vaginal delivery whether you do your bit or not.Don't misbehave with the healthcare professionals when in labour pain or when you are not able to take a decision about whether to have epidural or not.I realize that it is the most important day for you,so be better prepaired for it.If you feel that you are not prepared for a vaginal delivery despite reassurances from your doctor,please opt for a caesarean.There is no face loosing in it.We all are different and respond to various situations differently.
Of these 9 ladies my team did manage to deliver 8 of them vaginally but it was a nightmarish experience for all of us.Sorry if I have hurt you but............we can support you during labour but can't take away your pain if you don't wish to have labour analgesia.And nothing wrong in that as well but then please understand 'labour pain is an integral part of labour'.Bear it!!

Saturday, June 16, 2012

Address the is curable

The' sixth sense'

You must have heard  story of some old doctor who could just by looking at a person or by just feeling the pulse of the patient could diagnose his or her medical condition.I have heard of it.Is it possible?Or just another Indian story of mystic and magic.Even I used to think.
My brother Dr Shamsher Dwivedee who is a neurologist by profession was at my place.He is known in his circle as an excellent clinician who hardly prescribes any investigations.His students have so many time told me his stories when he used to make a clinicial diagnosis on examinaton with hardly a test or two for which any other routine consultant would have prescribed many more to come to the same diagnosis.That is his clinical sense.Last week he was at my place in Gurgaon.A men came to meet him for some official work.After sorting out the work,suddenly my brother asked him,''so you drink alcohol every day.Isn't it?' That guy was taken by surprise and after few seconds admitted that since last 5 to 6 months he was drinking every day.Then bombarded my brother,you are about to spoil your liver and in no time you will be bed ridden,Go get a scan done and that will show a fatty liver.Poor thing he went for a scan that very day and it did show fatty liver and haepatomegaly.
I was surprised.I asked him,bhayia,did you know he drinks so much.He said ,no.Then I asked did he smell of the alcohol because to me he looked quite sobre and I couldn't smell any alcohol.My Bhayia said..........nope,he didn't smell of alcohol either.I said then what?He smiled and said that is clinical sense what people misunderstand as the sixth sense.He said that after observing patients for years you can judge and observe the various features,body habitus which gives the dcotor a clue.
He told me story of British doctor Dr Brain,who on looking at a lady advised Laparotomy.On laparotomy ovarian cancers were detected and Dr Brain had thought her to be a patient of paraneoplastic syndrome.
For a while we talked about the progress the science of medicine and how much it has developed ,but with development of the science of medicine the arts of medicine is dying away.The clinical sense is the arts of medicine.
Dr Shamsher Dwivedee awarding an ISCR award winner
Last month a couple came to me.that lady was having some vague breast pain.I examined......axillary breast tissue.Asked her if she could be pregnant.Both of them looked at me surprisingly.Not possible.Have not even missed my periods.Had sex only once or twice.just not possible.I still advised to have a urine pregnancy test if she missed her periods.Within 10days they were back..........UPT was +VE..................Clinical sense :-) They went for a TOP though !!

Monday, June 11, 2012

Complication part 3

Not long back.......may be One and a half years back I conducted a very straight forward vaginal delivery of a lady at around midnight.She had a previous caesarean section.It was a baby boy after a daughter.The couple was really happy.The family was complete and it was a vaginal delivery after previous caesarean section.I congratulated them and they thanked me.I left the lady to catch my sleep.After may be 2 hours I got a call from Dr Sweta,Our registrar on call.The patient was bleeding heavily and the medicines for stopping PPH ( post partum bleeding) were not working on her.I rushed to the hospital.She was bleeding in fact.Uterus was well contracted on abdominal examination.So had the scar of caesarean given way?I did an internal check up and found the scar to be intact.The lower segment and the portion below previous scar felt very floppy with a fibrous ring where previous scar was.This floppy lower segment wasn't contracting.I did bimanual compression which didn't work.Syntocinon,ergometrine,carboprost.........all in vain.Tried to put a Foley's  Cather inside the uterus.Tried to put roller gauze.Nothing worked.the floppy lower segment continued to bleed.Patient's husband and her family who were rejoicing in the room were called and informed of this sudden unexpected complication.My team had ordered for blood products.I got the Lady shifted to the OT.Dr Priya immediately intubated her anticipating her to collapse.By then I had taken consent from her husband to operate on her to stop the bleeding.I did an internal iliac artery ligation.It seemed that the bleeding was decreasing in amount and I decided not to perform a hysterectomy ( removal of uterus).Got her shifted to the ICU. It seemed like early DIC was setting in.
Mumtaz mahal who died of PPH
It was difficult for me to perform the surgery,keep the patient's family informed and keep their morale up as well.I was tired,stressed and sleepy.In between the patient's husband wished to me to comment if shifting her to Max saket was a good idea as it is a bigger hospital.I told him that I think I can manage her equally safely in Max Gurgaon provided he had the faith and trust and also that I would never let my personal ego come in between his wife's life and proper care.He agreed to stay with me.(Later on he did confess that he was under tremendous pressure from his family members to get her shifted to Max Saket under some older Gynaecologist,but he went ahead with his gut feeling).  After 2 hours of sleep I went and assessed her.Still her dressing was getting wet.Her Haemoglobin had again fallen down though her clotting profile was improving.There wasn't any active vaginal bleeding but I wasn't sure whether she had stopped to bleed or was still bleeding inside.I had done my best and only measure which I could have taken was to remove her uterus.I wasn't sure whether that was necessary or not.I involved another Gynaecologist to give her opinion as personally I believe when under so much stress one's judgment can be blunted.Even that Gynaecologist wasn't sure whether this patient needed observation for some more time or a hysterectomy.A falling Hb wasn't letting me relax and yes I was afraid that I might loose the patient if frank DIC sets in.Ultimately I decided to remove her uterus and within 24 hours she was taken second time in the OT ,this time for removal of the uterus.I swear I was mentally and physically tired.Felt like had had not slept for days altogether.Every hour i was talking to the patient's husband.I requested Dr Shalabh  to sit in the OT waiting lounge,just in case I felt too tired and drained to come and help me for the hysterectomy.(The reason I have mentioned this fact is to tell you how drained and  vulnerable a doctor feels in such situations.No one wants to loose one's patient.Normally I don't need a Surgeon to support me for my surgeries,but yes here I needed that mental support).Surgery went well.......her bleeding stopped.She recovered from her early DIC.A strong lady herself she didn't end up in post traumatic stress.........I did.It took me a while to forget that bloody night.In this blog itself I have mentioned this incident before.......It was scary.I am thankful to the whole family who showed trust in me,stayed at Max Gurgaon and gave me the opportunity to take care of her.

Saturday, June 9, 2012

World Incontinence week

From 18th to 24 th june,we are celebrating world continence week.If you visit me at max hospital gurgaon for incontinence related issues ,your consultation and evaluation will be free.
Do you have any of these conditions
You can get rid of your diapers in 15 minutes!!

  • Leak When You Cough, Sneeze, Laugh, Jump Or Lift Something Heavy?
  • Limit Your Social Activities Due To Urinary Problems?
  • Get Up At Night To Pass Urine More Than Once?
  • Know This Problem Can Be Solved With Medical Treatment?
.If on evaluation you are found to be fit for a 15 minutes life changing surgery (TVTO) you would get 20% discounted surgery on the occasion of world continence week

complication -Part 2

I was the registrar on call at my UK hospital.There was this third time pregnant Lady in the antenatal ward who was escorted by the midwife to the labour room.She had a bad CTG suggestive of foetal distress.I offered her an instrumental delivery as she was already fully dilated.She declined.She wished to have a caesarean instead.No amount of convincing worked.So here she was under GA and baby was out in no time.....healthy baby girl.I started closing the uterus.Even with easiest of pace it never takes me more than 20  minutes to complete a caesarean section and here I was still closing the first layer of uterus and 1st layer was still Little wet with blood.There was a small ooze which I was not able to stop.The protocol in UK is to call the consultant if expected blood loss has already been more than 1000 mls in a caesarean.It was much less than that but a bleed like this should have been controlled by couple of figure of eight stitches I reasoned to myself.No harm in calling the on call consultant.I tried to reserve my call for help for dire emergencies,so consultants used to beat their super prompt arrival on such occasions.When my consultant arrived in not more than 10 minutes ,he was surprised to see me call him for such a small ooze.And he was relieved as well that it won't take him much time to fix it and he can go back home and sleep peacefully.Almost 2 hours past by and still the bleeder was bleeding.The uterus had started to become atonic.Her blood pressure was going low.I could see the sweat drops glistening on my bosses forehead.He asked me to call the senior most consultant and when he didn't pick the phone at 3 am in the night,he asked me to call the second senior most consultant.The senior consultant arrived but by that time the uterus was boggy,patient was in DIC(disseminated Intravascular coagulation) and was bleeding from all over.I don't know how but superior and inferior mesentric arteries were also bleeding.
Her BP showed a measly 15 mmHG.My heart sank.I imagined this case to get a mention in the forthcoming edition of 'why mothers die'?
Then the senior most consultant talked to the patients husband and decided to proceed for caesarean hysterectomy.By this time she had already receive approx 35units of PRBC apart from other blood products.She was still bleeding.I remembered such a case which had happened in a famous corporate hospital of Delhi where a politician's wife operated by renowned gynaecologists of India(Mumbai) had ended in DIC and then the vascular surgeon had saved her.So,I suggested to call the vascular surgeon and my boss agreed.That lady was slowly taken care off.In between I performed 2 instrumental delivery as well :-) while my bosses kept on struggling.It was the longest caesarean I have ever been washed for......9 hours.The patient survived.My name didn't become a part of confedential in inquiry,but it was a close save.I was shaken for 12 hours as I had to come back for another night on call and didn't have the luxury to destress my self.
The patient had post traumatic stress disorder for some time.But was discharged on day 5th of the caesarean with a healthy baby but minus her uterus.For a week I kept on explaining everyone ,consultants,midwives and colleagues that it wasn't my fault.It wasn't actually no ones.In hind sight a consultant told me why didn't you give her an option of forceps under general anaesthesia rather than a caesarean.
Anyways after a week,I was asked to present this case in front of the department and was declared 'not guilty'.

Friday, June 8, 2012

When things go wrong........complications as you call them!!

To err is human and to forgive is goes the saying.This is an apt saying but unfortunately,I am a doctor,I can cause error but will I get forgiveness so easily..........?May be not.It is the nature of my job.I am dealing with the most precious creation of the world ',the human life' and thus my margin of error is very limited.
Now I wish to let the ghosts of Aamir Khan and his Satyamev Jayte to get buried in it's grave ........enough of it......whether he says sorry to IMA ore not,whether the people think that all doctors are unethical,I need to rest this issue in peace for the sake of my peace.I love my profession,operating fibroids, endometriosis,polyps,removing uterus ,delivering babies and much more.I need to perform my work with full concentration or I might harm you.A pilot's job is very with so many lives but still they have an auto pilot.We have nothing like an auto surgeon.
Few days back one of our registrar's went to take a preoperative consent from a Lady for some surgery(not my patient so don't know it in great detail).The Lady's husband asked the young doctor whether she was taking this consent to cover the incompetency of the operating Gynaecologist.She was taken aback.......It is a medico legal requirement after all.
In all fairness to my patients I would say that none ........not a single patient of mine has shown any distrust towards the doctors.And I am greatful to you.
In my career spanning almost 13 years post PG,I have had my shares of complications.......not many ...........I can count them on my finger tips and in fact  remember all of them to write all the details about it.
One such incident took place around 3 years back.A lady with previous 3 caesareans and very big cysts on both ovaries presented to me.She had adenomyosis as well.Her CA 125 was elevated ( the ovarian cancer marker).She went to various hospitals and decided to get operated by me.Herself a qualified professional,her husband is also a well connected person.So we decided on removing the uterus and both ovaries,send it for frozen section to rule out any evidence of cancer and if any evidence of cancer to proceed for lymph node removal and staging.While removing I realized that her uterus was badly stuck with the bladder due to the previous caesareans.And despite my all gentleness I had inadvertently opened her bladder.My assistant Dr Deepa M,actually was quite shocked.But these things do happen when you are performing a complicated surgery.What is important is to identify it and to rectify it.I completed the whole surgery,frozen section suggested a benign condition.I repaired her bladder and post surgery informed the patient of her bladder getting accidentally opened.In post op periods her intestine took longer than normal to come out of the effect of surgery and she developed paralytic ileus.She had apparently a tendency for post op paralytic ileus,as she told me that she had a similar problem after each of her caesareans.She had Catheter in her bladder for about a week.In the meantime her ileus got better as well.3 years later she is fine with no problems at all.
When she left the hospital after about a week she left as a happy patient.But that was her who had 'forgiven' me.What would have you done.Done the same or declared me an incompetent surgeon who did a complication and covered it with the blanket of consents?Just think for a while and let me know your opinion.

Tuesday, June 5, 2012

The other side of Mr Rai's and Mr Aamir Khan's story.......The concerned Nephrologist's version of the story