Today we had a very interesting discussion on natural childbirths. It made me think deeply about some of the conversations I keep having with expectant mothers on how to overcome the fear of labour.I think as doctors we focus very little on the psychological preparation of the expectant mother.May be we need to have support from counsellors and childbirth educators for giving more time and understanding the mother----to hear her story! We need to tell our mothers that labour is a kind of  physiologically monitored physical and psychological strenuous event in their lives which they have to deal with like any other challenging phase in their lives. They should practice regular meditation and focussed concentration breathing to divert their minds away from unfounded fear. There is nothing to fear when you are surrounded by relatives and health professionals you trust .Like they say what you believe in actually happens ,so believe in your body,mind and the ability to birth your own baby because nature has made us that way. 

What should I expect from my ultrasonologist?

Ultrasonologists and obstetricians  are having a unique relationship in private obstetric practice .It is time that they educate each other about many obstetric issues for the overall well being of the mother and baby. As an obstetrician in private practice  I feel that obstetricians and ultrasonologists are giving advice to patients independent of each other leaving the patient highly confused .Recently I saw  an ultrasound report from a renowned ultrasonologist mentioning occipitoposterior position of the baby at 38 weeks on routine scan and even telling the patient that it is an unfavourable position for normal delivery. First of all position of the baby before start of labour does not change the obstetrical management in any way. It is only the presentation cephalic or breech ( head at lower pole or not) which matters. Secondly why confuse the patient with a statement which does not alter management in any way? 90% of occipitoposterior positions will turn to the more favourable occipitoanterior position. The ultrasonologist in question felt that he was helping the patient and the obstetrician by remarking on an  additional foetal parameter .But in reality he or she implanted seeds of anxiety and fear of failure in the patient”s mind before she began her labour journey. Most of the time we as obstetricians don’t give feedback to the ultrasonologists thinking they will not understand .

By the way this patient had an uneventful vaginal delivery

WHAT DO YOU EXPECT YOUR DOCTOR TO TELL YOU IN THE FIRST ANTENATAL CONSULTATION?

  Think hard. You are an educated professional enthusiastic expectant mother at 30 or above. But unfortunately discussions regarding pregnancy and childbirth have been taboo at home. Whatever knowledge you have gained till now is clearly from” hearsay” Now suddenly everybody has some valuable knowledge to offer you regarding a forbidden topic .Most of them will tell you about negative experiences that they have heard of and a list of thing that you should not do to avoid poor outcome. A time may come that you are filled with negative stories and you constantly think how you could prevent anything bad from happening. You expect your doctor to tell you all the things in a systematic manner that you should or should not do to prevent all the nerve racking medical horror stories you have heard.

So you go for the first antenatal consultation feeling powerless vulnerable and totally dependent on the medical community. Typically in a typical urban hospital set up the primary care provider is an obstetrician who has trained for 6 years intensively to detect associated disease in pregnancy and minimise complications arising from them. When you go and tell her how powerless you feel and how worried you are that something bad is about to happen and you expect her to give you a long list of things you should do or not do

Well she is quite uneasy. There is no such divine list she can offer you. Pregnancy is not a disease and complications happen in only 10 to 15% women and it is absolutely imperative to also add that no doctor however competent can prevent most complications from happening. If miscarriages have to happen they will happen ,if pregnancy induced hypertension has to happen it will happen and if  preterm labour has to happen nobody on earth can prevent it. Then   Why are doctors required?

Many doctors also seek the answer to this question .There are some doctors who feel so powerless and vulnerable that they wonder whether their being or not being there could ever make a difference There are others who take full advantage of the complexity of the situation and project themselves as being always in control  as if to say that every good outcome is their credit and  the fact that the mother did not have a miscarriage or a growth restricted baby is because of the excellent care that they have provided.

As expectant mothers it is very important that your expectations match the reality .Our job as doctors is to make you feel confident and project on the positive aspects of pregnancy care. There are some inherent limitations of medicine because of which some serious complications cannot be foreseen or prevented. But nevertheless you should empower yourself  by knowledge, innate positivity and leading a healthy lifestyle. You must have the confidence in yourself that things are fine because things are usually fine most of the time. After all   you don”s sit on the driving seat of your car everyday thinking   that you will have an accident today!

To DEmedicalise normal Births

I am reconnecting with you all after a long time. Meanwhile our whole team  is working towards a lot of issues I discussed in my previous post. We are very focussed and commited to DEmedicalising normal births .We believe that the maternity care system has to have radical changes to make our dream come true. An optimal outcome for a mother who comes for her delivery in a hospital is much beyond a healthy baby and healthy mother.It is about how you enjoy your pregnancy,it is about creating confidence in the mother on herself ,it is about how well you are prepared physically,mentally and spiritually for this journey.This is team work and a very important member of this team is the pregnant mother herself and her partner .How well they understand that birthing is a physiological process and the trust that is created between them and the caregivers go a long way in determining the experience of care.The emphasis on not only what happens but how it happens!

What you can do to reduce your chances of caesarian section ?

It"s lovely to talk to you again.I also welcome the new members to the site.Although I don't know you personally I feel a special bond towards you as I can share my thoughts with you.
You will all agree that a lot of us lead a very sedentary life without realising it's fall out and implications. I may be busy the whole day but most of my time is spent sitting or standing and talking. These  nonphysiological postures and workpattern put a heavy strain to our body physically and mentally. Have you ever wondered why other mammals and even primates do not need assistance for birth the way most humans do? Also why first births are apparently so much more difficult now compared to when your grandmother or great grandmother delivered?
Let me try to answer the first question first. Humans are the only mammals who are exclusively bipedal. This probably makes our pelvis narrower and less weight bearing. Also our brain size has been increasing over centuries and therefore the ratio of human baby"s  head size to maternal pelvic diameter has been steadily increasing. This is a part of natural evolution and individually we cannot do much about it. The human birth is a fascinating phenomenon.The preparatory phase of labour starts days to weeks before the actual labour.To begin with the cervix or the mouth of the uterus starts loosening out .The connective tissue thins out and the cervix becomes softer and stretchable.There are some irregular uterine contractions (cramps)which may make you slightly uncomfortable.It is very important to wait it out and bear this slight discomfort. If you do regular exercise and walk for atleast 30 minutes a day your chances of going in spontaneous labour may increase.Besides there is medical literature to show that exercise can shorten labour and reduce your need for labour pain relief.

Labour support

Today I want to reemphasise the need of a good birthing support partner in labour. The fact that positive birthing support can do wonders for the labouring woman is now evidence based. We all know and it is proven by research that continous support in labour decreases the need of labour analgesia( pain relief) and medical interventions in birth. The big question is now who gives support because it is very important to understand that just like positive support can do wonders ,negative presence (not intentional of course) can do everything to break the morale of the patient.You are the husband of the expectant mother and you cannot see her in discomfort.Ofcourse we appreciate your love and concern for her but it is also your responsibility not to feel weak at this moment and keep reinforcing her positively,keep telling her she can do it,physically support her and positively divert her mind.This is how you can actually express your love for her and not start getting nervous yourself and panicking.We ofcourse appreciate that every human being is not cut out for this and if you feel you cant do it it is better to stay away and let another person who is better suited for this take over, it could be  your wife's sister or friend
      We are very sensitive to this issue and we are trying to give 1;1 continous medical support to all our mothers but your understanding and passive and active support to your wife and medical caregivers can go a long way in helping the expectant mother to do all she can for a natural noninterventional birth experience. 

Public Private Health Divide

THE GREAT PUBLIC PRIVATE HEALTHCARE DIVIDE-------a doctor speaks 

      

      I joined the medical profession in 1992 technically speaking, as I was a  medical student before that. There is a vast difference in the way I think, the way I behave and the way I treat from then and now.I used to look for role models then and in my own way I used to always find them.The calm surgery house surgeon who taught me for hours how to put intravenous cannulas,the surgery senior resident who taught me how to remain awake after a 24 hours duty and still have the enthusiasm to teach the steps of appendicectomy to an intern he would never meet after a week,the medical senior resident who grilled us for hours during morning rounds just to empower us with more knowledge. There was always so much to learn and so much to imbibe that not a moment was spent in procrastination.The medical education in the preclinical days however was quite ruthless according to me. Hours of cramming fat dissection books ,15 people working on the same cadaver,tough practical exams after every two months when the demonstrator would get some animal like pleasure in announcing your pitiable low scores.The behaviour of the professors and teachers made one feel that failing in one of these exams was akin to damaging your career for ever. In the first six months of my starting the medical journey,there wasn’t a single night when I didn’t cry myself to sleep thinking that I wouldn’t be able to go to college the next day. The students who had their siblings as seniors generally fared well.They already knew what was expected and accordingly crammed up the inticracies of arteries, mucles and veins in advance.Every thing that we gobbled up whether it was biochemistry,physiology,pharmacology,microbiology and so on was far removed from the reality that we would be facing in the subsequent years.But looking back I think that every single day of those long years of hardships toughened us up for the long corrugated journey of the medical world.

It was during internship that I got a taste of professional life that we would be facing in future.The plight of poor patients moved me and I realised how poor people suffer in disease physically and socially. Women coming in with a 2 gm%  haemoglobin with inversion uterus,women brought in a charpoy with rupture uterus ,women with intestine hanging out of uterus dumped in front of us and relatives untraceable for hours after that. I could see the obstetric residents working for hours and still not being able to do enough.  During my postgraduation years that I came face to face with human suffering and physical pain. There was no room for exhaustion. During the 12 hour continous duty we would see sometimes the whole spectrum of obstetric mishaps starting from intractable postpartum haemorrhage to secondary abdominal pregnancy.We could save some and we couldnt save some but each patient taught me to be a better clinician and a more humanitarian doctor.When I moved to the private sector due to lack of government jobs in the city the scenario drastically changed. The medical practice in government hospitals is so different from care giving in private hospitals that as a doctor I took very long to adjust to it.In the former you had these scores of patients in the labour room  where you are taking a quick history ,doing quick obstetric examinations and the whole focus is on making a fast diagnosis and expediate the treatment so that there is a speedy turn over of patients. Beds were always in demand and the quicker you were in managing the patient the more competent you were considered by your seniors.  I slowly and steadily improved my clinical and surgical skills. By the time I became a senior resident I became quite settled in the art  and science of Obstetrics. We were often so enthralled in the variety and complication and the challenge of certain neglected cases that we were quite unaware of the social and humanitarian aspects of these  patients. You could say work was worship for us and for the 36 continous  hours that we were on duty virtually nothing crossed our minds except how efficiently we could clinically manage our patients. We were also under pressure of proving ourselves academically to our teachers so that we could be better clinicians. If we could diagnose a case of silent rupture of uterus or a very rare case of secondary abdominal pregnancy we got a pat on the back and we felt proud about saving a precious mother”s life . It really did not matter to our seniors how much we talked to a sick patient or how much time we spent in counselling the relatives. The fact is that we really did not have so much time because  we had to move on to the next patient who required our help. At the end of each month we had an audit in which the focus was how much better and quicker we could have clinically managed a patient leading to lesser morbidity. The scenario drastically changed when we moved onto the private sector. It took a long time for me to understand and accept that 60% of the gynaecology patients belonging to the upper socioeconomic class who reported to the OPD (outpatient department) did not really need any significant expert medical help but only routine check ups and a lot of assurance and counselling. Now how good a doctor you are was solely decided by the patient and her attendants and their perception on the other hand was quite often solely depended on your bedside manners and how well you talked to them.  Clinical skill and clinical outcome was important but secondary. It was a lot about how patient you are in answering sometimes the same questions over  and over again during a consultation. In this context I must also add that the success of the practitioner is mostly depended on the referrals she gets either from other doctors or from her old patients. In the process many bright but novice less manipulative private practitioners have failed to even make a beginning in this terribly competitive world of private practice. As a society we are constantly losing out on the services of some very well trained young enthusiastic doctors . In a  country with an appalling doctor patient ratio of 1:1700 it should ideally never be the doctor”s responsibility to procure patients. The private sector is profit driven. Academic medicine which provides the medical profession the wellspring to thrive, study, carry out research, evaluate, treat, learn and improve is often ignored.Academic medicine and Research also contributes to the overall progress in medicine and brings down health care costs .  I know that one day in the far distant future things will change and more public private partnerships  will create a balance between the overworked exhausted doctor in the public sector and the underutilised dedicated young doctor in the private sector.I am also optimistic because I know some young hospital directors who are aware of this paradox and want to change the situation to improve the overall quality of health care at all levels

Woman centered Labour care

As a pregnant mother you must appreciate that pregnancy is not a disease ,so the care that we give you should also not be like a disease .We are not really treating you for a problem but we are monitoring you to see that you dont develop a problem or even if you do we try to decrease the severity of the compilcation.Another remarkable feature of labour care is that it may last for hours together and plan of care may change over minutes and seconds whereas the treatment of most diseases is usually not so variable over such a short period of time .Therefore do not approach labour with too much planning and calculation Labour is best left the way it is ---natural.So many people ask me ---so Doctor when will it Happen? No doctor can predict a natural event.We can only tellyou that the chances of natural labour happening are maximum from 2 weeks before your due date to one week after your due date.
You must also realise that the beginning of labour is usually a slow and gradual process and some changes are happening in your body for weeks before the actual start of labour.Therefore there is nothing to panic when labour starts.You may get regular crampy abdominal pain the frequency of which will go on increasing and the interval will go on decreasing.You may also have excessive vaginal discharge  and watery discharge .On reaching the hospital the doctor will do a gentle pervaginal examination to confirm whether  you are in labour .Even after you are in established labour you may take 6 to 8 hours to deliver.This is the first stage of labour when it is very important to relax,walk around,have hot/cold baths,listen to music and to have a good labour support partner  

woman centered pregnancy and labour care

Another very misunderstood aspect of pregnancy care is miscarriages which happen early in pregnancy usually before 10 weeks. Most or almost all of theses miscarriages are usually not preventable whatever you eat or dont eat,exercise or don't exercise.Often expectant mothers tell me that all her family members have asked her to take complete bed rest in the first three months to prevent miscarriages.The poor mother is literally terrorised to believing that she should not climb stairs,she should not walk,she should not sit on the floor and so on and so forth.Common sense tells us that if these activities really led to miscarriages then the women labourers would never have children. The fact is that most early miscarriages most of the time happen because of genetic mutations when the sperm and ovum(egg) fuse to form a zygote and these are not dependent on any external factor.So the mothers need not blame themselves for such a mishap.The good news is that the chance of these genetic accidents happening again is very less.So even after two such miscarriages the chance of successful pregnancy happening is around 70--80%.

Women centered labour care

It is great communicating with expectant mothers and understanding their concerns and expectations. Recently one of my collegues was very offended when she had to do a cesarian section for a patient at 2 am and the patients' relatives were very angry as they were under the impression that if the doctor was trying so hard and waiting for so long it had to be a normal delivery.The doctor was highly offended because she felt that she had used all her energy and hard work for a patient and finally due to no fault of hers ,a cesarian happened.The patient instead of feeling grateful is actually blaming her for the cesarian section. As doctors, sometimes we often take a lot of things for granted. Most patients understand a lot of things which we may not necessarily communicate to them. Most patients know that if labour progress is not satisfactory a cesarian will happen.But there is a minority of patients who will not understand that fully.They will assume  that the doctor can assess in early labour whether cesarian will happen and some kind of mismanagment has happened if they were not told beforehand that a cesarian will happen. Our communication channels with the patient should be multi dimensional so that we understand the patients well.Otherwise we may have done a great job but the patient"s perception will be very different 

In continuation of my discussion about overmedicalisation of pregnancy and labour care ,I further want to say that a lot also depends on your approach to pregnancy as" would be" mothers.Please do not consider pregnancy as a medical disease.Remember that no matter what you do and whatever care you take ,how so ever number of ultrasounds you get done or dont get done,whatever number of antenatal check ups you go for ,whatever rest you take or you dont take ,most pregnancies and labour will be uneventful and safe.This is specially true for most mothers like you who are well nourished and are not suffering from any major medical illness.Remember as an expectant mother you should spread positivity which will have a positive influence on your family and care givers.When you are over anxious you may induce your  care giver to worry more about you and that may unnecessarily cause more interventions .Let me give you an example. Say Mrs B has had two miscarriages at 2 months which does not increase the risk of fetal loss at term .But once she is 38 weeks ,she is overanxious and feels there are decreased fetal movements.She comes to the emergency and a CTG and USG are reassuring.After 2 days she again rings up the doctor saying movements are less. Again the doctor does the CTG and finds her movements are fine.When she comes back a third time with the same complaints because of anxiety the medical care giver will in all likelihood induce her (Arificial pains )

Rinku Sengupta@SBISR: Patient centered Approach to labour care

Rinku Sengupta@SBISR: Patient centered Approach to labour care: Today let us talk about postdated pregnancy that is pregnancy that continues beyond your expected date of delivery.In recent times we have seen a large number of mothers being induced for this indication .Let us see why.As the pregnancy continues beyond term,the chances of liqour (water around the baby) getting less and the baby getting less oxygen increases. But nobody knows the exact risk of that happening with you at say term +1 day,term+2 days and so on and so forth.After doing research on thousands of women some international medical organisations have found that the risk of leaving a low risk pregnancy beyond 41 weeks (calculated from first trimester ultrasound) is slightly high compared to leaving them beyond that time awaiting spontaneous labour.The absolute risk to the babby is still very low ,approximately 500 inductions or more may need to be done to save one baby from this risk. Therefore it is important to understand the risk benefit balance in every decision.

Patient centered Approach to labour care

Today let us talk about postdated pregnancy that is pregnancy that continues beyond your expected date of delivery.In recent times we have seen a large number of mothers being induced for this indication .Let us see why.As the pregnancy continues beyond term,the chances of liqour (water around the baby) getting less and the baby getting less oxygen increases. But nobody knows the exact risk of that happening with you at say term +1 day,term+2 days and so on and so forth.After doing research on thousands of women some international medical organisations have found that the risk of leaving a low risk pregnancy beyond 41 weeks (calculated from first ultrasound) is significant.
continued.........

It has been a long time time since I have written on this blog.Being an obstetrician now for almost 20 years ,I feel time has come for us doctors in private practice to empower our patients with more knowledge so that they can participate in managment and do not feel a particular managment plan has been imposed on them .Ofcourse I am only talking from the point of view of pregnancy and labour managment which in recent years is getting more and more medicalised. I am only talking about those mothers and their families who typically visit Private hospitals in metropolitan cities.These mothers are educated,professionally qualified and usually read up a lot about pregnancy and child birth on their own before visiting the doctor.To these mothers I want to give evidence based medical information.I want to make them understand that most medical situations are not black or white ,there are a lot of grey zones.Let me give you an example ,there is this lady who has epilepsy and is pregnant and wants to know whether she can continue to take antiepileptic drugs which are known to be teratogenic (harmful to the fetus).My advice would be that she would have to continue the drugs (under medical supervision) as the risk of not taking it can outweigh the risk of taking it.If she has a epileptic fit then she and her baby could be in grave trouble but the risk of the drugs could be kept low depending on the dose and type of drug. Therefore everything rests on this risk benefit ratio and it is like a weighing balance that all us doctors are mentally using everytime we prescribe you an antibiotic,we decide for induction, we decide to give you antihypertensive drug,decide for cesarian section so on and so forth. I think we need to give you universal evidence based information regarding the risk benefit analysis for situations that are available and then make you participate in your care.

Mistaken Identity

A couple of days back I came across a patient who because of some misunderstood and misinformative content on website decided to be operated by a different doctor in the same institute. Such loss of trust and rejection by the patient on the basis of something read on a website which I wasn’t even aware of surprised, shocked and hurt me. I google searched my own name and came across a document which I presumed was read by the above mentioned patient. The content of the document (http://www.gmc-uk.org/static/documents/content/Sengupta_(MP)_-_PUBLISHABLE_Mintues_-_16-24_Feb_10.pdf) seemed to indicate that a particular namesake doctor practising in UK has been implicated in a fitness to practice case. I would like to clarify that it is a mere case of namesake identity crisis as there are many Rinku Senguptas in different professions and except for sharing the similar phonetic name I have nothing in common with them. I feel that a similar misunderstanding could have happened to various other patients and could repeat itself in the future. As often happens to a sensitive doctor caught in the modern day myriad of increasingly commercialised medical practice one comes across some disconcerting harsh realities, difficult to face, tough to accept and hardest to convey. With a feeling of being choked, muted and stunned and in an attempt to clarify my position and disseminate my side of the story I conceived the idea of initiating this blog. I reiterate that I have never been trained or practiced in UK and am working in Sitaram Bhartia Institute of Science and Research, Delhi since May 2002. Since 2022 April I am working in Madhukar Rainbow Hospital Malviya Nagar Delhi