The Family

THE FAMILY!

Rohan came to Aruna auntie’s house for his mid-term break. By the time he reached home with ammamma and amma it was 7:00 pm. Ammamma, Amma and Rohan headed straight to the kitchen to see if dinner was ready. But Aruna auntie was not in the kitchen. She was found talking on the mobile phone in her bed room. Ammamma asked her if dinner was ready. After all she had given instructions on the phone about dinner- the menu and the recipe for each item on the menu. Aruna auntie was surprised “I thought the menu was for dinner(?)”. She was reminded that it was already an hour passed Rohan’s dinner time at school and he was ‘starving’. Aruna auntie says “Oh! OK” and starts preparing the dinner with amma and ammamma’s help.

 As soon as the dinner is ready Rohan piles up 6-7 chapattis (or was it 9-10) on his plate and sits down at the table to eat. Toward the end of the meal Rohan is seen squirming and making faces.

Amma: Rohan, do you want to use the loo? (that is the term used by the family for the wash room)

Rohan: Um… Yep!

He gets up and heads towards the loo. But returns to the kitchen within seconds.

Amma: What?

Rohan: There is no toilet paper in the loo.

Ammamma: Wash with water!

Aruna: Oh! I can give you kitchen towel or paper serviette.

Rohan is a bit dazed with the attention he has created. In the middle of this Suresh Uncle walks into the room to get a snack from the fridge and says “You have really shot up since I saw you last, Rohan”.

Rohan: Um…. Yes! I’ll use the kitchen towels

He grabs what Aruna auntie is holding out and disappears for a while. He reappears in the kitchen looking happier. Ammamma, Amma and Aruna auntie are still eating their dinner at the table.

Ammamma: Did you wash?

Aruna: Did you wash?

Rohan: No, I used the kitchen towel

Aruna: Did you wash?

Rohan: No, I used the kitchen towel.

Amma: Aruna auntie means your hands, Rohan.

Rohan holds up his hands which are obviously wet.

Ammamma: With soap?

Rohan: Yes

Aruna auntie: Which soap? Did you find the hand soap?

Rohan: Yes, the push-push one. (Accompanied with hand motion to imply he used the hand wash soap from the dispenser)

Ammamma: Do you want to finish up the dinner?

Rohan: Can I not? I am kind of full.

You would think kids in the family will get a complex the amount of talk which goes on about what happens in the loo. But the adventures (or misadventures) in the loo is discussed very openly in the family. It all can be traced to GG who when she was alive could be heard confiding to her son “my bowels have not moved today”.

This was followed by Suna auntie who would shout out “I want to use the loo first” as the car entered the garage after the family outing to the church, dinner out or just about any outing.

Announcements like ‘I want to do the big job’ or ‘I want to download’ or just plain ‘I want to shit’ is heard commonly in the middle of family games like Pictionary/dumb charades.

Even post adventure comments like ‘it looked like a flower/train’ (from children) to ‘I had to use soap’ is heard.

But with Rohan don’t forget to ask ‘have you flushed?’ Cos after all the questioning about his use of the loo Amma went to use the loo and found he had not flushed!!

Emergency tubectomies??

EMERGENCY TUBECTOMIES???

        Recently, while reflecting on my experiences in mission hospitals, one thing that made me pause, smile to myself and shake my head was having done emergency tubectomies.  One may wonder why it was such an unusual thing. To understand that, one needs to know that tubectomies themselves are procedures that the family puts a lot of thought into before deciding to make the woman under go it.  Another thing that one needs to understand is what constitutes as an ‘emergency’.  I would call a procedure an emergency if the procedure is done after routine working hours and definitely if the procedure is done  after the surgeon has gone to bed for the night. So, is emergency tubectomies (not LSCS+TL) done anywhere in the world? I would not think so. But I can remember at least two occasions where I had to perform tubectomy in the middle of the night while I worked in Uthraula between 1998-2003.

       The first was on a woman who had undergone 6 deliveries before. And all of them were in the house with just the relatives’ support. But on this the 7^th pregnancy she had problems during her labor. Labor was taking too long. And so she was brought to the hospital late at night. As she had been seen in 2 places before arriving in the hospital it was difficult for me to make an assessment clearly. So, I wanted to do a ‘trial forceps’- it is when we take the woman into the operation theater and under spinal anesthesia apply forceps to deliver the baby. If forceps is successful it is a good thing but in the event that the forceps was not successful then the woman is already under anesthesia and so she can be delivered by LSCS.

      But from my experience with working in Utraula, I knew that if I told the woman and the husband that I will try forceps and if not successful then do a LSCS, what would usually happen is that they will not give consent for LSCS. Uneducated people think in absolutes. If there is a way to deliver vaginally why do an LSCS? So, the usual course of action when I post a woman for ‘trial forceps’ is to get consent for LSCS. And in the OT, forceps is applied and if it was successful the relatives are more than grateful that a smaller and cheaper procedure was done which allowed them to return to their house within 3 days. So, when I informed the family about the need for LSCS they also wanted a tubectomy done as they were just fed up with the troubles they had just been through for a pregnancy which they did not really want.

       In the OT the forceps delivery went on smoothly and I would have just had to send the mother and baby back to the ward and go back to bed. But, there was this woman who was under anesthesia for a 7^th delivery. If I discharged her the next day there was likelihood that she will be pregnant again in 2 years’ time and may attempt a termination and die while attempting it or may die during delivering the next time. So, I walked out of the OT and talked to the family. Since, they had already given consent for tubectomy with LSCS would they consider having the tubectomy even though she had delivered vaginally? And yes they were!!

That was how I did my first EMERGENCY TUBECTOMY.

The lessons I would like to pass on especially to young doctors-

1. In remote areas where a woman is in labor for a long time and has been treated in 2-3 places before they arrive in the hospital, it is always advisable to try vaginal delivery. It is not a sign of your ignorance if you are not able to say after examining the woman if she can be delivered vaginally or not. The whole scenario changes after anesthesia has been given. And why is it advisable to deliver vaginally? You reduce the risk of wound infection and peritonitis. And also financially it is cheaper for the family- the procedure charge is less and the hospital stay is less.

2. How you communicate to the family depends on knowing what they are capable of comprehending.

3. Have a uniform protocol but be also willing to change when the need arises- individualizing the care.

4. Always be willing to think outside the box.

EMERGENCY TUBECTOMIES???

        Recently, while reflecting on my experiences in mission hospitals, one thing that made me pause, smile to myself and shake my head was having done emergency tubectomies.  One may wonder why it was such an unusual thing. To understand that, one needs to know that tubectomies themselves are procedures that the family puts a lot of thought into before deciding to make the woman under go it.  Another thing that one needs to understand is what constitutes as an ‘emergency’.  I would call a procedure an emergency if the procedure is done after routine working hours and definitely if the procedure is done  after the surgeon has gone to bed for the night. So, is emergency tubectomies (not LSCS+TL) done anywhere in the world? I would not think so. But I can remember at least two occasions where I had to perform tubectomy in the middle of the night while I worked in Uthraula between 1998-2003.

       The first was on a woman who had undergone 6 deliveries before. And all of them were in the house with just the relatives’ support. But on this the 7^th pregnancy she had problems during her labor. Labor was taking too long. And so she was brought to the hospital late at night. As she had been seen in 2 places before arriving in the hospital it was difficult for me to make an assessment clearly. So, I wanted to do a ‘trial forceps’- it is when we take the woman into the operation theater and under spinal anesthesia apply forceps to deliver the baby. If forceps is successful it is a good thing but in the event that the forceps was not successful then the woman is already under anesthesia and so she can be delivered by LSCS.

      But from my experience with working in Utraula, I knew that if I told the woman and the husband that I will try forceps and if not successful then do a LSCS, what would usually happen is that they will not give consent for LSCS. Uneducated people think in absolutes. If there is a way to deliver vaginally why do an LSCS? So, the usual course of action when I post a woman for ‘trial forceps’ is to get consent for LSCS. And in the OT, forceps is applied and if it was successful the relatives are more than grateful that a smaller and cheaper procedure was done which allowed them to return to their house within 3 days. So, when I informed the family about the need for LSCS they also wanted a tubectomy done as they were just fed up with the troubles they had just been through for a pregnancy which they did not really want.

       In the OT the forceps delivery went on smoothly and I would have just had to send the mother and baby back to the ward and go back to bed. But, there was this woman who was under anesthesia for a 7^th delivery. If I discharged her the next day there was likelihood that she will be pregnant again in 2 years’ time and may attempt a termination and die while attempting it or may die during delivering the next time. So, I walked out of the OT and talked to the family. Since, they had already given consent for tubectomy with LSCS would they consider having the tubectomy even though she had delivered vaginally? And yes they were!!

That was how I did my first EMERGENCY TUBECTOMY.

The lessons I would like to pass on especially to young doctors-

1. In remote areas where a woman is in labor for a long time and has been treated in 2-3 places before they arrive in the hospital, it is always advisable to try vaginal delivery. It is not a sign of your ignorance if you are not able to say after examining the woman if she can be delivered vaginally or not. The whole scenario changes after anesthesia has been given. And why is it advisable to deliver vaginally? You reduce the risk of wound infection and peritonitis. And also financially it is cheaper for the family- the procedure charge is less and the hospital stay is less.

2. How you communicate to the family depends on knowing what they are capable of comprehending.

3. Have a uniform protocol but be also willing to change when the need arises- individualizing the care.

4. Always be willing to think outside the box.

Is CTG machines/ EFM necessary in mission hospitals in India?

(CTG-cardio-tocography. EFM-Electronic Fetal monitoring)

There is no real reason for anybody to listen to my ramblings but I would like ramble on anyway because I find that I am in a unique situation having worked as a consultant Obstetrician in rural hospitals without EFMs, followed by a stint in managing a busy labor unit in a tertiary level hospital with availability of EFM and again going back to rural mission hospitals. And also because you will be spending a large sum of money in buying an EFM machine and you need to know if what you get is well worth the money spent.

First let me quote from journals about electronic fetal monitoring. Most reviews about EFM say

                       – It is one modern medical intervention that was introduced into the market without prior randomized controlled trials.

But subsequent studies show that

                       -It does not decrease the perinatal deaths but increases the C-section  and operative vaginal delivery rates wherever it has been used. >250% without scalp pH and 30% with-in LSCS and >30% in operative vaginal deliveries)

                      - It has reduced the incidence of sudden intrapartum fetal deaths but that has not been statistically significant.

                      - There has been an increase in neonatal seizures when EFM is not used but these seizures are not associated with long term sequelae.

(Check RCM Evidence based practice for midwife-led care in labor 4^th edition and ACOG practice bullatin)

Second let me try to logically think through what you are trying to achieve with EFM and if EFM does what you except it to achieve.

Do you want EFM to diagnose fetal distress or avoid fetal distress?

If it is to avoid fetal distress than the next question is; is there a ‘pre fetal distress’ sign/pattern? The answer is NO. History and examination can do a better job of identifying a fetus at risk of developing fetal distress.

Does doing an admission test help in identifying this? NO.

Does EFM identify fetal distress? YES. But it also identifies a lot of other conditions which are not fetal distress and hence the high CS rates with the use of EFMs.

In the international classification of fetal heart rate patterns; Category 1 is when the fetal acid-base status is normal. Category 2 is when fetal acid-base status is unndetermined and Category 3 is when the fetal acid-base status was abnormal at the time of trace. In other words the fetal acid-base status may be abnormal temporarily and become normal spontaneously or with measure such as intrauterine resuscitation.

Abnormal fetal heart rate patterns include category 2 and category 3. On an average you will see category 2 trace 90% of the time compared to <1% of category 3 traces.(these figures are quoted randomly) Both of them warrant additional tests-in the case of category 2 to identify the actual fetal distress. And in category 3 to see if fetal distress is still present. Without these additional tests LSCS rates will be high making health care expensive for the individual woman and family and also to the country. It also adds significantly to chances of complications and maternal deaths. (Auxiliary tests for fetal wellbeing include VAST-vocal auditory stimulation test, Scalp stimulation and Scalp pH.)

Thirdly if EFM were doing their job well (identifying fetal distress) why would there be a continued search for better methods of identifying fetal distress? But we know that fetal pulse oxymetry and fetal ECG are being researched to replace EFM.

Fourthly; from my experience with working with and without EFMs- while at the remote rural hospitals I thot that it would be so wonderful to have a EFM when I was faced with meconium stained liquor (EFMs will be able to identify past dates requiring amnioinfusion from fetal distress); when faced with abruption or any other APH (to identify fetal distress early); and when faced with complication like eclampsia or fetal IUGR which is likely to lead to fetal distress.

But during my stint in tertiary level centre I found that LSCS was done for Meconium stained amniotic fluid (grade 2); for abruption irrespective of the stage and for women with eclampsia and IUGR. If we prescribe to the phrase ”action speaks louder than words” it would seem that the very people who use EFM do not believe that it would help them in identifying or avoiding fetal distress in these high risk conditions. (RCOG guidelines say that EFM if not the ideal method of fetal monitoring in low risk women but the ideal method of monitoring in high risk women is not known yet)

Finally having an EFM definitely blunts the ability to use your clinical acumen. Identifying scar dehiscence would be a wonderful use for EFM in mission hospitals. But even for this indication I found a strict adherence to selection of cases for trial of scar reduces the very incidence of scar dehiscence and scar rupture during labor.

As for use of EFM on those woman who are on oxytocin drip to identify fetal distress due to hyper stimulation-isn’t it logical to identify hyper stimulation itself? Isn’t it a better strategy to train nursing and medical students and staff in monitoring uterine contractions? Or is it that we can’t really be bothered to be a learning team caring for every aspect of managing a woman in labor? Because if your team cannot monitor a woman’s contractions;what are they doing in the labor room?!

Train your nursing and medical staff in decision making skills and skills in monitoring uterine contractions and listening to fetal heart sounds. Believe me it is a better option.