Category: The Dr.Says


Labour of love

Labour is the process that signifies events that indicate the impending birth of a child.

SINCE time immemorial, the pregnant mother undergoes a process called labour before the unborn child is delivered. It is only in recent times that this process has been circumvented by Caesarean section in certain groups of pregnant women.

Labour comes about following changes in the biochemical structure of the uterus, leading to regular uterine contractions of sufficient intensity, frequency and duration that results in the gradual thinning and opening up (dilatation) of the cervix.

It is the practice to inject a newborn baby with vitamin K to prevent haemorrhagic disease of the newborn. If there are objections to an injection, the midwife should be notified as oral doses are available.

Labour is a clinical diagnosis. Cervical dilatation without uterine contractions is suggestive of cervical weakness, whereas uterine contraction without cervical dilatation does not meet the definition of labour.

There are three stages in labour. The first stage involves the gradual cervical dilatation from 0 to 10cm, and the descent of the foetal presenting part, ie head or buttocks (breech position) through the mother’s birth canal. The second stage involves the baby’s birth, and the third stage involves the separation of the placenta from the uterine wall and its delivery.

Start of labour

The uterus, which comprises muscle, starts to contract regularly when labour commences. There is noticeable hardening of the abdomen during a regular, painful contraction, and softening when the contraction ceases.

The signs and symptoms of the start of labour include:

·A feeling that the foetus has dropped lower into the pelvis (lightening). This occurs between a few weeks to a few hours before labour starts.

·A pink or bloodstained vaginal discharge from the mucous plug at the cervix (called show), which is pushed out when the cervix starts dilating. This occurs between a few days to the start of labour.

·Backache and/or period-like cramps.

·A dribbling or gush of liquid when the “water bag” (waters) surrounding the foetus breaks.

·Contractions.

If there is bleeding or the waters break, one should proceed to the hospital immediately, even if there are no contractions.

False labour

The uterus may contract on and off long before labour starts. These contractions (Braxton Hicks contractions) are sometimes mistaken for labour. They occur irregularly from the middle of pregnancy onwards and are usually not painful, although they sometimes can be painful.

There are ways of distinguishing true from false labour. Braxton Hicks contractions are irregular and do not increase in intensity with time. True labour contractions are regular and increase in intensity, with shortening of the interval between contractions as time passes.

Braxton Hicks contractions may stop with walking, resting or even a change of position. True labour contractions continue irrespective of what one does. A practical method of distinguishing between the two is to time the duration of the contractions.

It would be prudent, when in doubt, to seek professional assessment by a doctor or midwife. A vaginal examination would provide definitive information about the start of labour.

Stage one

This stage involves the gradual thinning and dilatation of the cervix from 0 to 10cm and the descent of the foetal presenting part, ie head or bottom (breech) through the mother’s birth canal.

There are two phases.

The initial latent phase involves the thinning and dilation of the cervix from 0 to 3cm. This may take days or hours during which there are contractions, which may be regular or irregular. Some women feel the contractions whilst others do not notice them at all.

The subsequent active phase is characterised by strong and painful contractions, which last 30 to 60 seconds. The cervix dilates from 3 to 10cm. The interval between the contractions is between three to four minutes apart initially, and later, it shortens to about one to two minutes apart as the cervical dilatation gets to 8cm or more.

There may be an urge to go to the toilet as the presenting part exerts pressure against the rectum in its passage down the birth canal.

Once labour is established, the first stage lasts between 6 to 12 hours in those having their first baby. If one has had a baby previously, this stage is often shorter.

The mother and foetus are monitored throughout labour. This involves checking the mother’s general condition, blood pressure, pulse, contractions and pain levels.

The foetal heart is monitored throughout labour to detect any changes which may indicate that the foetus is in distress. This is done by periodic listening every 15 minutes with a foetal stethoscope or a hand-held ultrasound device; or continuous electronic monitoring with a device called cardiotocograph (CTG) through a monitor fastened by a belt to the abdomen.

An alternative approach is through an electrode placed on the foetal head after the waters have broken and attached to the CTG.

It may be necessary to speed up labour if the contractions are not strong or frequent enough, or because the foetal position is abnormal. The doctor will explain the need and the manner in which this will be done.

During this stage, you can walk around the labour room if you feel like doing so. Fluids and food can be taken unless advised otherwise. (Pain relief will be discussed in a subsequent article.)

You should not feel embarrassed by your appearance or behaviour, as the midwife has seen it all. It is important to adhere to the midwife’s advice to resist the urge to push until the cervix reaches 10cm dilatation.

Stage two

This stage starts from the time the cervix is dilated to 10cm until the baby is born.

The contractions are strong, regular and appear to merge from one to another. There is an urge to bear down and push as if you have not passed motion for a few days.

This can be done by taking two deep breaths at the start of the contraction and pushing downwards for as long as is possible until the contraction stops. Another breath may be taken if necessary.

One needs to rest after each contraction and gather up the energy for the next contraction. The attending healthcare professional (accoucheur), who is a midwife or doctor, will provide the encouragement for this hard work.

There are various positions for this stage. They include lying in bed with pillows propping up the back, lying on the side, sitting, kneeling or even squatting.

What is important is to choose a position that one is comfortable with. It may help if you have tried out some of the positions beforehand.

If it is the first baby, this stage can last up to one to two hours. If one has had a baby previously, this stage is frequently much shorter.

When the presenting part appears at the vulva, which is the opening of the birth canal, the mother may feel that the area between the vulva and anus (perineum) is being stretched. The accoucheur will advise the mother to stop pushing and to pant some rapid short breaths.

This provides time for the perineum to stretch without tearing, thereby facilitating a gentle birth of the baby. However, the perineal skin may tear in some mothers.

If there is evidence that the perineum is going to tear or if there is a need to hasten the delivery, the accoucheur will ensure it is anaesthetised before making a cut in the perineum (episiotomy), which will be stitched up later.

After the foetal head is delivered, a gentle push is all that is necessary for the rest of the baby’s body to be delivered. The umbilical cord is then cut. (A subsequent article will discuss vaginal breech delivery.)

Stage three

This stage involves the separation of the placenta from the uterine wall and contraction of the uterus, which pushes the placenta out of the birth canal. The process takes between five to 30 minutes after the baby’s birth.

The accoucheur usually administers an injection of a hormone called oxytocin to assist the process, and for the uterus to contract to reduce heavy blood loss, which occurs in some women.

The cuddling of the baby after birth helps in bonding between mother and baby. This can be done before the baby is cleansed of the messiness on the skin. As many labour rooms are air-conditioned, it is essential that the baby is kept warm.

It is the practice to inject a newborn baby with vitamin K to prevent haemorrhagic disease of the newborn. If there are objections to an injection, the midwife should be notified as oral doses are available.

The baby will be weighed, measured and examined by the midwife and/or paediatrician. An identification band with the mother’s name will be attached to a part of the baby’s body.

There are occasions when the mucous in the baby’s nose, mouth and throat needs to be sucked out. There are also occasions when the baby requires assistance to start breathing.

The mother will then be assisted in washing and freshening up prior to transfer to the postnatal ward.

>Source: Dr Milton Lum

Planning in advance about the types of pain relief you want during labour can make the experience a less painful one.

LABOUR is a painful experience. The pain is felt especially in the active phase of the first and second stages. Pain depends on various factors like the strength of contractions, the size and position of the foetus, and the individual’s pain threshold, which can vary markedly.

There are several ways in which you can deal with labour pains. A discussion with the doctor or midwife at the antenatal clinic and on admission to the labour ward, on the methods of pain relief available, would be useful.

A relaxed person copes with labour pains better. Try learning about what happens during labour, and how to relax from the doctor, midwife and/or from antenatal classes. – Reuters

It would also be helpful to plan for your pain relief. However, you should always keep an open mind about pain relief, however high your pain threshold is. The mother-to-be may find that more pain relief is required than anticipated, or more effective pain relief may be advised by the attending doctor or midwife (accoucheur) to facilitate the labour and delivery.

Self-help

A relaxed person copes with labour pains better. There are a number of ways of self-help. They include learning about what happens during labour from the doctor, midwife and/or from antenatal classes, learning to relax, and taking deep breaths.

When in labour, it would be helpful to find a comfortable position by walking, lying on the side, rocking back and forth, or kneeling. It would also be helpful if someone, whether it be spouse, relative or friend, is around during the labour to provide support.

However, there is no need to worry if there is no one, as the attending midwife will provide support.

Systemic analgesia

Analgesia is the provision of pain relief without a loss of feeling or the ability to move about. The pain does not disappear, but its intensity is lessened.

Systemic analgesia is the injection of medicines, usually narcotics like pethidine or morphine, into the muscle of the thigh or buttock, or into a vein. The injection acts on the whole body, and not on a specific part. The injections help in relaxation, thereby decreasing the intensity of pain.

In an epidural, a tiny plastic tube is inserted into the epidural space just outside the spinal canal, and a mixture of local anaesthetic and narcotic is injected into this tube to numb the nerves involved in conveying pain signals from the uterus.

When an intramuscular injection is given, it takes about a quarter of an hour or so to act, and it is effective for about two to four hours. If given intravenously, its action is within minutes.

The side effects include drowsiness, difficulty concentrating, and nausea. If the medicine has not worn off by the second stage, it can affect the mother’s ability to push.

If given too near the second stage, it may slow the baby’s reflexes and the initiation of breathing.

However, there are medicines that are given to counteract this effect on the baby’s breathing.

Local analgesia

Local analgesia provides pain relief for a specific area of the body. It has no effect on uterine contractions.

Local analgesia is used if a cut is made in the area between the vulva and anus (episiotomy) prior to the delivery of the baby, or to repair a perineal tear after the delivery.

The local analgesia does not affect the foetus, and there are usually no side effects for the mother after it wears off.

Gas and air

This mixture of 50% oxygen and 50% nitrous oxide, called Entonox or “laughing gas”, does not remove the pain, but it makes it more bearable. It is easy to use and the patient is in control. It is useful in the active phase of labour, when the contractions are stronger, longer and more frequent.

It involves breathing in the Entonox through a mask which is held by the labouring mother-to-be. As the Entonox takes about 20 seconds to act, slow, deep breaths should be made at the start of the contractions.

There are no harmful side effects for the foetus. However, some women feel dizzy, sleepy, have difficulty concentrating or experience nausea. These will cease when the use of Entonox is stopped.

If the Entonox is insufficient for pain relief, systemic analgesia can be given.

Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation (TENS) involves taping electrodes, which are connected by wires to a battery-powered stimulator, to the back. The emission of small amounts of current by the stimulator is controlled by pressing on a button.

TENS acts by stimulating the body’s production of its own painkillers (endorphins), and by reducing the transmission of pain signals to the brain by the spinal cord.

TENS is effective during early labour when there is low back pain. It has not been shown to be effective in the active phase of labour.

If there is interest in using TENS, it would be advisable to learn how to use it in late pregnancy. Some hospitals have TENS devices. If they do not have, then one should ask how to rent the device.

There are no known side effects.

Regional analgesia

Regional analgesia involves pain relief for a part of the body. In the case of labour, the nerves that transmit pain in the uterus and birth canal to the brain are numbed by analgesic medicines. Regional analgesia provides effective pain relief in labour with few side effects.

The types are epidural, spinal, or a combination of epidural and spinal analgesia. As they are provided by an anaesthetist, it is important to check if such a service is available at the place of birth.

An epidural involves inserting a drip into an arm vein, after which the mother-to-be is asked to lie on the side or sit up in a curled position. The anaesthetist will clean the back with an antiseptic solution and inject local anaesthetic to a small area.

A tiny plastic tube is then inserted into the epidural space just outside the spinal canal and a mixture of local anaesthetic and narcotic is injected into this tube to numb the nerves involved in conveying pain signals from the uterus.

It takes about 20 minutes to do an epidural, and an additional 15 minutes for it to work. Some adjustments may be necessary if the epidural does not work perfectly. When the medicines wear off, a top-up is done by the midwife.

Continuous foetal heart monitoring is done by attaching a belt and an ultrasound transducer (CTG) to the abdomen. Alternatively, an electrode may be attached to the foetal scalp instead of the abdominal transducer.

A spinal block involves an injection into the sac of spinal fluid below the level of the spinal cord. Pain relief is almost instant and lasts an hour or two. It is best for pain relief in the second stage.

A combination of epidural and spinal block has the benefits of both.

Although uncommon, the side effects and risks of regional analgesia occur occasionally. Fluids are run in through the drip in the arm to prevent a drop in the mother’s blood pressure, which occurs sometimes. The legs may feel heavy.

As the second stage may be prolonged, it is important to act on the midwife’s instructions to push, to avoid instrumental delivery by forceps or vacuum extraction.

The injection of less anaesthetic towards the end of the first stage may help in the pushing out of the baby naturally.

Some mothers may experience difficulty in urination, requiring the insertion of a catheter into the bladder.

About less than one in 100 mothers may get a headache, which usually goes away after a few days. If the headache does not go away or it becomes severe, it can be treated.

There may be some backache for a day or two after regional analgesia.

Occasionally, the medicines may inadvertently be injected into the veins in the epidural space, which are swollen during pregnancy. This causes rapid heartbeat, dizziness, and a funny taste or numbness around the mouth, at the time of insertion. If such symptoms occur, the anaesthetist should be informed immediately.

Regional analgesia does not cause drowsiness or vomiting.

Hydrotherapy

Warm water helps one to relax. The Royal College of Obstetricians and Gynaecologists (RCOG), and the Royal College of Midwives (RCM) of the United Kingdom, support labouring in water for healthy women with uncomplicated pregnancies.

However, the jury is still out as to whether hydrotherapy provides pain relief.

With regard to birth in water, the joint RCOG and RCM statement in 2006 stated: “Informed choice on the benefits and risks of birth in water is clouded by the lack of good quality safety data. Although there is no evidence of higher perinatal mortality or admission to special care baby units (SCBUs) for birth in water, caution is advised because of small numbers, possible under-reporting of SCBU admissions, and exclusion of women who were in labour in water, but gave birth conventionally after complications.”

> Source: Dr Milton Lum

Induction and augmentation of labour are methods to facilitate the birth of a child under certain circumstances.

THERE are occasions when artificial starting of uterine contractions in an effort to achieve a vaginal birth is required. This is called induction of labour.

There are also occasions when labour, which has already started, needs to be given some assistance because it is not progressing, or it is progressing too slowly. This is called augmentation of labour; the word “augment” means “to make greater, increase, or more intense”.

Reasons for induction

Induction of labour is recommended if there are risks to maternal or foetal health.

Women with uncomplicated pregnancies are usually offered induction between 41 and 42 weeks of pregnancy (gestation) to avoid the risks of prolonged pregnancy, which include increased risk to foetal health or stillbirth.

There are no means available to detect the foetuses more likely to be affected by such risks. The exact timing takes into consideration individual preferences and local circumstances. If one decides not to have an induction, arrangements for increased monitoring of foetal well-being will be made.

Premature pre-term rupture of the membranes (PPROM) occurs occasionally. The maternal risks include infection and possible Caesarean section. The foetal risks include infection and the problems of premature birth. In general, induction is not carried out until after 34 weeks gestation unless there is evidence of infection or foetal compromise.

If labour has not started 24 hours after the membranes have ruptured after 37 weeks gestation, induction will usually be offered.

Induction will also be considered in maternal conditions like high blood pressure, poorly controlled diabetes, kidney disease and previous stillbirth, as well as foetal conditions like poor growth, too little amniotic fluid and foetal death.

Induction is not usually offered for those with previous Caesarean sections or breech presentation, or if there is suspicion that the foetus is large, unless there are reasons for not prolonging the pregnancy.

Induction is carried out for non-medical reasons in exceptional circumstances, like parental request or a mother living far away from a hospital. This is done only after 39 weeks gestation to reduce the risk of inducing a foetus whose lungs are not mature.

Reasons for augmentation

Augmentation is required if labour is abnormal, or normal labour needs to be speeded up because of maternal or foetal risks.

When the cervix reaches a dilatation of 4cm, subsequent dilatations are at a rate of 1cm per hour in a mother having her first baby, or faster in a mother who has given birth before. Augmentation will be considered if this is not occurring.

Augmentation is also considered when there is concern about the problems of prolonged labour, like maternal medical conditions, damage to mother’s pelvic floor, bleeding after delivery (postpartum haemorrhage), respiratory problems in the newborn, etc.

Cervical assessment

Changes in the cervix occur a few weeks before spontaneous labour begins. An assessment of the cervix will be done prior to an induction. The examination provides information about the readiness of the cervix for labour.

A system called the Bishop score based on the dilation, effacement (length), station, position and consistency of the cervix is used in this assessment. The score ranges from 0 to 12.

A score of 8 or more (“favourable cervix”) indicates that the likelihood of spontaneous labour or the response to induction is high. A score of less than 6 indicates that the cervix may not be ready for labour.

Membrane sweep

At the time of cervical assessment, a membrane sweep will be offered to help the mother go into spontaneous labour. This involves the insertion of a finger into the cervix and making a circular movement to separate the membranes from the inner lining of the uterus. If this is not possible, massaging the area around the cervix may achieve the same effect.

The foetal heart, which is checked before and after the membrane sweep, should have a normal pattern.

The membrane sweep may lead to some bleeding and/or discomfort.

A membrane sweep is usually offered at 40 to 41 weeks to a mother having her first baby, and at 41 weeks to a mother having her subsequent baby. Additional membrane sweeps can be carried out if spontaneous labour does not start.

Membrane sweep is considered an adjunct to, and not a method of, induction.

Medicines used to induce labour

Prostaglandin (PG) E2, which is available as a pessary, tablet or gel, is the preferred method, and is inserted into the vagina. One dose is inserted, followed by a second dose after six hours if labour has not been established.

Misoprostol, a PGE1 analogue used to prevent non-steroidal anti-inflammatory drug-induced (NSAID) stomach ulcers, is used in inducing labour when there is an intrauterine foetal death. It is taken orally or inserted vaginally.

Although unlicensed for induction of an uncomplicated pregnancy, it is used in many countries because it is much cheaper than PGE2.

Sometimes, an intravenous drip containing oxytocin is used to hasten up labour. Oxytocin is not used within six hours after insertion of PGE2 gel, or with PGE2 in situ, or within 30 minutes of its removal.

It may take some time for labour to start with induction, especially if the cervix is unfavourable. Once labour commences, it should proceed as in spontaneous labour.

Amniotomy

This is the breaking of the membranes with a hook-like device. It can start contractions, or it can make the contractions stronger if labour has already started.

It is not used as a main method of induction unless there is reason for not using medicines, eg an increased risk of uterine hyperstimulation.

Induced labour is usually more painful than spontaneous labour. Various methods of pain relief should be discussed prior to admission to the hospital. Planning in advance can help make the labour less painful.

It is recommended that there should be facilities available for electronic monitoring of the foetal heart and contractions during induction or augmentation.

A normal foetal heart rate pattern should be confirmed prior to the administration of medicines to the mother, after which, there should be continuous foetal heart monitoring.

When the foetal heart rate pattern is confirmed normal, intermittent checking of the foetal heart with a foetal stethoscope or an ultrasound may be used to monitor foetal well-being.

If the foetal heart rate pattern is abnormal, immediate steps should be taken to address the problem.

If induction fails, an assessment of the maternal and foetal conditions will be made. The doctor will recommend another induction or a planned Caesarean section depending on each mother’s individual condition.

The methods of augmentation in the first stage include intravenous oxytocin and adequate pain relief.

The methods of augmentation in the second stage include intravenous oxytocin, reducing the weakness and numbness of epidural or spinal analgesia, delay in pushing until the foetus is way down in the pelvis, the presence of a support person for the mother, and changing the mother’s position.

There is no scientific evidence to support the following as methods of induction – herbal supplements, homeopathy, castor oil, enemas, sexual intercourse, hot baths and acupuncture.

Provided there are medical reasons, induction and augmentation can be potentially life-saving. In the case of induction, labour can be pre-arranged for mother and doctor.

Risk assessment

The risk of prostaglandin and oxytocin induction is uterine hyperstimulation, which is defined as five or more contractions in 10 minutes in a period of 30 minutes, contractions lasting more than two minutes, or contractions of normal duration occurring within 60 seconds of each other.

There may or may not be foetal heart rate changes.

If not managed early, hyperstimulation leads to poor placental blood flow, resulting in decreased foetal oxygenation, foetal compromise, and even, foetal death.

Another risk is that of potentially life-threatening uterine rupture, especially in those with previous Caesarean section or uterine surgery.

Other risks include maternal and foetal infection; increased risk of foetal distress and unplanned Caesarean section, where risks are more than that of planned Caesarean section; increased risk of postpartum haemorrhage; increased risk of epidural analgesia and instrumental vaginal delivery; and increased risk of breathing problems in the newborn, especially if delivery occurs before 39 weeks gestation.

Medical problems prior to or during pregnancy may exacerbate these risks.

Discussion between mother and doctor about the benefits and risks of induction and/or augmentation, as well as the alternatives is essential. The doctor will make known the reasons for the intervention and provide information about the when, where and how of the intervention. Various methods of pain relief will be discussed.

It is vital to also discuss what the options are, should induction fail.

> Source: Dr Milton Lum

Understanding the reasons and risks for a Caesarean section.

MOST women have vaginal deliveries. There are occasions when delivery is by Caesarean section (CS), which is an operation that involves a surgical incision made in the abdomen and uterus, through which the baby is delivered.

The operation can be planned (elective), in which the need for it is apparent during pregnancy, or unplanned (emergency), when the operation is necessitated by complications which arise during labour.

According to the National Health Care Establishments & Work Force Statistics published in 2011, the overall CS rate in 2009 was 20.8% of all deliveries. The CS rate in the private sector was 30.3%. The CS rate in the public sector was 18.1%, compared to 15.7% in 2006. The overall CS rate in Kuala Lumpur was the highest at 29.5%, compared to 11.5% and 11.6% in Sabah and Kelantan respectively.

Medical reasons for planned CS

There are several medical reasons, and they are discussed below.

The foetal position may be bottom first (breech). The obstetrician will usually offer an external cephalic version (ECV), which is a procedure in which an attempt is made to move the foetus round to head first with the obstetrician’s hands on the mother’s abdomen.

However, ECV cannot be done in mothers with certain conditions (contraindications). If so, or ECV has been unsuccessful, a CS is often offered.

CS is done if the foetus’ longitudinal axis in relation to the mother (lie) is transverse and ECV is contraindicated or unsuccessful.

Multiple pregnancy, usually twins, may be another reason. They may be premature, the first twin may be a breech presentation, or they may be sharing a placenta. However, CS is not indicated if the first twin is presenting by the head. It is not guaranteed that CS reduces the risks of twin delivery.

CS may be considered if the foetus is small because of prematurity or growth retardation, and other complications are present because of increased risks in-utero or around the time of birth.

CS is done if the placenta is sited at the cervical canal (praevia), the diagnosis of which is usually made at 32 to 34 weeks gestation. A colour ultrasound, and possibly magnetic resonance imaging (MRI), is often done to check if the placental attachment is abnormal (morbidly adherent placenta), which is another reason for CS.

CS is done if the mother’s pelvis is small in relation to the size of the foetal head; her blood pressure is very high; or she has a medical condition, eg heart problem, that increases her risk during a vaginal delivery.

CS may be considered if there are certain circumstances in a mother who has HIV, herpes or hepatitis to reduce the risk of transmission of the infection to the foetus during delivery.

An older mother’s chances of having a CS are increased because of increased risk of complications like high blood pressure, diabetes, large foetus, breech presentation, placenta praevia and slow progress.

Medical reasons for unplanned CS

An unplanned CS may be carried out for various reasons, ie concerns about maternal or foetal health, labour is not progressing, failed induction, or going into labour before a planned CS.

It may not be possible for the obstetrician to have a full discussion with the mother and/or her spouse in an emergency, especially when the baby needs to be delivered quickly.

Procedure

CS involves making an incision, usually almost horizontal, on the abdomen at the top of the pubic bone. This permits another almost horizontal incision in the uterine muscle to deliver the baby, after which the placenta separates from the uterine wall and is removed.

A hormone injection, which causes the uterus to contract, is given to reduce blood loss. The incisions are then stitched back together.

A vertical abdominal incision is made if there is a previous scar. A vertical uterine incision is made in certain circumstances like transverse lie, previous vertical incision (classical CS), etc.

CS is done under regional (epidural or spinal) or general anaesthesia. In the former, the lower part of the body will be numb, and the mother will be awake. A screen will be in place so that the mother does not have to see her operation.

In the latter, she will be asleep. There is an increased risk of vomiting, especially if the CS is unplanned. If this occurs, stomach contents can get into the lungs (aspiration) and cause serious inflammation (aspiration pneumonitis).

Eating during labour may increase the chances of aspiration. The risk of vomiting is reduced by not eating, but taking drinks with the same concentration of electrolytes and sugar as the body’s (isotonic drinks), antacids and medicines is allowed.

The operating table is slightly tilted during a CS to reduce the chances of low blood pressure from uterine compression of the abdominal blood vessels. A tube is usually inserted into the bladder (catheter) to empty it, and keep it empty.

After the CS, the mother will be observed by a trained nurse on a one-to-one basis until she is breathing normally and able to communicate clearly. The heart and breathing rates, blood pressure, and pain relief will be checked initially at half-hourly intervals and subsequently at hourly and longer intervals.

Pain relief will be provided with epidural analgesia, injections into the muscles or veins, tablets, or suppositories. The mother can control pain relief herself with injections into her veins (patient-controlled analgesia or PCA).

Antibiotics are not usually prescribed unless there is evidence of infection.

Fluids, and then food, can be taken soon if there are no problems. The catheter will usually be removed when the mother is mobile, or 12 hours after the last “top-up” of the regional analgesia.

There may be some difficulty initiating breastfeeding, but once started, breastfeeding will be no different from those who had a vaginal delivery. Care of the baby is no different from that of any other newborns.

The obstetrician will discuss the reasons for the CS before discharge from the hospital, or later if it is so preferred by the mother. The mode of delivery in future pregnancies should be part of this discussion.

The hospital stay is usually three to four days. Earlier discharge can be considered provided mother and baby are well, and there is adequate support at home.

Advice about post-natal care, possible complications of CS, pain relief, and wound care should be provided.

Medical attention should be sought if there increased, irregular or painful vaginal bleeding, pain on passing urine, leakage of urine, cough, pain or swelling in the legs, or breathing difficulties.

It will not be possible to carry out activities like exercise, carrying heavy things, having sex, or driving, immediately after discharge from the hospital. They can be started when one is able to, and they do not cause pain.

If unsure, a discussion with the obstetrician and/or midwife would be helpful.

Risks

The risks to the mother include infection of the wound and/or the uterus, excessive bleeding that may require removal of the uterus (hysterectomy), damage to the bladder or the tube that connects the kidney to the bladder, blood clots (thrombosis) in the legs or pelvis, which may be life-threatening if part of it dislodges and goes to the lungs (pulmonary embolism), and longer hospital stay.

There are also risks to the baby. Accidental cuts on the baby’s skin when the uterus is incised occur in about two in 100 babies delivered by CS.

The most common risk is that of breathing difficulties, which occur in about 35 out of 1,000 babies delivered by CS, compared to five in 1,000 babies delivered vaginally. Their breathing may be more rapid immediately after birth and the first few days of life (transient tachypnoea). This usually resolves within two to three days. The risk of baby’s admission to intensive care may also be increased.

The risks of anaesthesia to mother and baby have to be considered too.

Planned CS may reduce the risk of pain in the area between the vagina and anus (perineum), and injury to the vagina.

The risks to mother and baby are usually increased in unplanned CS due to problems in pregnancy or labour.

A CS does not increase or decrease the risk of breastfeeding problems, postnatal depression, other psychological problems or pain during sex.

A CS does not increase or decrease the risk of the baby having serious complications like bleeding in the skull, cerebral palsy, nerve injuries or death. These rare complications affect less than 20 in 10,000 babies.

Reducing the chances of CS

The measures include having another person for support throughout labour, induction at 41 weeks gestation, use of a chart (partogram) to monitor the progress of labour, availability of foetal blood sampling if electronic foetal monitoring is used, and decision-making by a senior doctor, usually a consultant obstetrician.

The obstetrician will discuss the reasons whenever a patient requests a CS. If there are no medical reasons for the CS, an explanation of the risks and benefits compared to vaginal delivery should be provided.

It is also essential to have a discussion with the anaesthetist and paediatrician. If there is anxiety about giving birth, arrangements can be made for discussions with healthcare professionals who can provide support during pregnancy and labour.

Some obstetricians will accede to a patient’s request for CS although there are no medical reasons. If the obstetrician is unwilling to do a CS for non-medical reasons, a referral to another obstetrician who does may be considered.

Source: Dr Milton Lum

Depending on various factors, vaginal birth after a Caesarean section is still possible.

ACCORDING to the National Health Care Establishments & Work Force Statistics published in 2011, the overall Caesarean section (CS) rate in 2009 was 20.8% of all deliveries. The CS rate was 30.3% in the private sector and 18.1% in the public sector. The overall CS rate in Kuala Lumpur was the highest at 29.5%, compared to 11.5% and 11.6% in Sabah and Kelantan respectively.

The question that everyone who has had a CS asks is how to give birth in the next pregnancy. One could have a vaginal birth or an elective CS.

In order for the obstetrician to provide the appropriate recommendation, he or she considers the reason(s) for the previous CS and what happened, the type of uterine incision made, whether there are any complications in the current pregnancy, and the views of the patient about the previous CS and current pregnancy.

Vaginal birth can mean a normal delivery or an assisted delivery with a forceps or ventouse. VBAC is an acronym for vaginal birth after Caesarean. The alternative is a planned CS, which is usually done at 39 weeks gestation, ie a week prior to the estimated date of delivery, unless there are maternal and/or foetal reasons for an earlier delivery.

Both VBAC and planned CS have risks, which are small.

Attempting a VBAC is not done when the mother has had two or more previous CS, rupture of the uterus in a previous pregnancy, a classical CS (the uterine incision is vertical) done previously or there are pregnancy complications in the current pregnancy that necessitate a CS, eg mother’s pelvis is small in relation to the size of the foetal head, or medical conditions like a heart problem.

In such situations, the obstetrician would advise a planned CS.

Advantages and disadvantages of planned VBAC

The advantages of a vaginal birth are increased likelihood of vaginal birth in future pregnancies, less abdominal pain, and no surgery, with consequent shorter recovery period and hospital stay.

There are disadvantages of a planned VBAC. One is unplanned CS, which occurs in about 25 out of 100 women. This is slightly more than the likelihood of CS if one is in labour for the first time, which is about 20 out of 100 women.

An unplanned CS may be done for various reasons, ie concerns about maternal or foetal health, labour is not progressing, failed induction, or going into labour before a planned CS.

Another disadvantage is the possibility of an opening appearing in the previous uterine scar (uterine dehiscence) during labour, which can lead to the scar splitting open (uterine rupture). This is potentially life-threatening for mother and foetus. It occurs in two to eight out of 1,000 women.

The likelihood of uterine rupture is increased if the previous uterine incision was vertical (20 to 90 out of 1,000 women), or if labour is induced.

The likelihood of uterine rupture in women who have had a previous surgical removal of fibroids (myomectomy) is unknown as data is lacking and contradictory. If signs of possible uterine rupture are detected, an emergency CS will be carried out.

The likelihood of having a blood transfusion in VBAC or infection is one out of 100 women when compared to a planned CS.

The likelihood of brain damage or death to the foetus in VBAC is two out of 1,000 women, which is similar to that of someone experiencing her first labour. This is in comparison to a likelihood of one out of 1,000 women in those who have a planned CS.

However, there is a need to balance this with the risks of a planned CS, which is discussed below.

There is no difference in risks between planned VBAC and CS in relation to hysterectomy, thromboembolic disease or maternal death.

There are increased risks with unsuccessful VBAC when compared to successful VBAC in that there is an increased risk of uterine dehiscence, uterine rupture, hysterectomy, transfusion and uterine infection.

Advantages and disadvantages of planned CS

The advantages of a planned CS include avoidance of the risks of labour, especially the one in 1,000 likelihood of foetal brain damage or stillbirth; almost no risk of uterine rupture; convenience and knowledge; and perhaps, choice of date of delivery.

As planned CS is usually done at about 39 weeks’ gestation, there is a one in 10 chance of going into labour prior to the pre-arranged date.

There are disadvantages of a planned CS. The obvious risks are the consequences of surgery. The risks to the mother include infection of the wound and/or the uterus, excessive bleeding, which may require removal of the uterus (hysterectomy), damage to the bladder or the tube that connects the kidney to the bladder, blood clots (thrombosis) in the legs or pelvis, which may be life-threatening if part of it dislodges and goes to the lungs (pulmonary embolism), and longer hospital stay.

In addition, the surgery will take a longer time and may be more difficult, with an increased risk of accidental injury to other abdominal organs, usually the bladder or bowel. This is usually due to the scar tissue from the previous CS.

There are also risks to the baby. Accidental cuts on the baby’s skin when the uterus is incised occur in about two in 100 babies delivered by CS.

The most common risk is that of breathing difficulties, which occur in about 35 in 1,000 babies delivered by CS, compared to five in 1,000 babies delivered vaginally. Their breathing may be more rapid immediately after birth and the first few days of life (transient tachypnoea). This usually resolves within two to three days. The risk of baby’s admission to the intensive care unit may also be increased.

The risks of anaesthesia to mother and baby have to be considered too.

The time needed to recover from a planned CS is more than that of a planned VBAC.

A planned CS will also be need-ed in subsequent pregnancies. Furthermore, the increased formation of scar tissue with each CS leads to an increased likelihood of the placenta in a subsequent pregnancy embedding into the scar and adhering morbidly to it (placenta accreta). This can result in increased bleeding risk, and even, a hysterectomy.

Management of pregnancy and labour after a previous CS

According to the guidelines of the Royal College of Obstetricians and Gynaecologists of the United Kingdom, the management of women who have had one previous CS is: “Women who have had an uncomplicated lower-segment transverse CS, in an otherwise uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of planned VBAC and the alternative of a repeat CS. A final decision for mode of birth should be agreed between the woman and her obstetrician before the expected/planned delivery date (ideally by 36 weeks of gestation). A plan for the event of labour starting prior to the scheduled date should be documented.

“Women considering their options for birth after a single previous Caesarean should be informed that, overall, the chances of successful planned VBAC are 72–76%.”

In order to have a safe labour after previous CS, a woman should be delivered in a hospital where immediate Caesarean section can be carried out. The woman and her obstetrician must be aware of the hospital’s resources, especially the availability of obstetric, anaesthetic, paediatric, and operating theatre staff 24 hours daily, 365 days a year.

The hospital should have a written policy regarding the processes for a possible immediate CS. An appropriate time frame of 30 minutes is considered adequate in the majority of instances.

Continuous electronic foetal monitoring of women attempting a VBAC is recommended.

The management of labour is similar to that of normal labour, with the proviso that oxytocic drugs have to be used judiciously.

It would be prudent for women who have had a previous CS to consult their obstetrician upon knowing that they are pregnant, to discuss the benefits and risks of a planned VBAC or planned CS, and to agree to a plan for managing their labour and delivery.

There must be willingness to accept a change in the delivery plan. This arises because of an alteration in the balance of risks and benefits consequent to a change in circumstances during pregnancy and/or labour.

In summary, the dictum “once a Caesarean, always a Caesarean” does not hold true in the majority of women who have had a previous CS, as three-quarters of women who have a planned VBAC achieve their objective.

There are many advantages of a planned VBAC in women whose current pregnancy is uncomplicated.

■ Source: Dr Milton Lum

Going into labour prematurely may have serious health consequences for the baby.

THE duration of pregnancy (gestation) is 40 weeks after the woman’s last menstrual period.

The majority of women give birth between 37 and 42 weeks gestation. However, about one in 10 women go into labour and give birth before 37 weeks. This is called premature labour.

Most premature labours occur spontaneously. There are some which are induced because the continuation of the pregnancy would pose risks to mother and/or foetus due to complications.

It must be emphasized that premature labour does not always result in premature birth.

The longer a foetus is in the mother’s uterus, the higher are the baby’s chances of being healthy. Premature birth has immediate and long-term health implications for the baby.

The earlier a baby is born, the higher is the risk to the baby’s health. One out every two babies born before 24 weeks live, and the other may die or have long-term problems.

On the other hand, the survival rate of babies born after 32 weeks is high, and most do not develop long-term complications.

The premature baby has immediate problems with breathing, feeding and maintaining temperature. This requires nursing in an incubator, oxygen by mask or ventilator, and feeding by a tube inserted into the stomach or into a blood vessel.

A premature baby requires nursing in an incubator, along with other medical equipment, that are only available in a NICU.

Premature babies born in a hospital with a neonatal intensive care unit (NICU) have the best outcomes.

However, not every hospital has a NICU. As such, it may be necessary to transfer the mother and baby to another hospital with a NICU, preferably before delivery or immediately after the baby’s birth.

The longer term problems of premature babies include developmental delay, asthma, behavioural problems and learning difficulties.

The earlier the premature birth occurs, the more likely the baby will be readmitted to hospital in the first few months of life, compared to those born at full term.

Why it happens

Why some women go into premature labour and others do not is not well understood. About half of premature labours occur in apparently uncomplicated pregnancies for unknown reasons.

What is known is that there are certain factors that increase the chances of premature labour. However, having a risk factor does not mean that premature labour will occur.

The risk of premature labour is highest in women who have a multiple pregnancy, who had a previous premature birth, or who have certain uterine or cervical abnormalities.

Most twins are born at or before 37 weeks. The average delivery dates for triplets is 33 weeks.

Incompetent cervix is a rare condition in which the cervix opens up weeks before full term.

The leakage of the amniotic fluid that surrounds the foetus in the uterus before full term (PPROM) is a common cause of premature labour.

Some studies associate this with uterine infections.

The management of PPROM is dependent on the amount of amniotic fluid lost, and the proximity to the estimated date of delivery.

Common or recurrent maternal infections, viz vaginal, cervical, urinary tract or sexually-transmitted infections are risk factors.

Any infection with a fever more than 101 degrees Fahrenheit during pregnancy is also a risk factor.

Chronic maternal illnesses like high blood pressure, diabetes or kidney disease are risk factors.

This is especially so when the condition is poorly controlled, and the only way to manage the worsening situation is to deliver the foetus. Sometimes, labour is induced, and at other times, it occurs spontaneously.

Abdominal surgery during pregnancy, eg for appendicitis is a risk factor.

In general, surgery is not done in a pregnant woman unless it is essential.

Placenta praevia is a condition in which bleeding occurs during labour from the placenta located over the cervix.

The mother will usually have a Caesarean section (CS) before labour starts, ie about 39 weeks.

Sometimes, bleeding occurs earlier, and if substantial, the CS done could result in premature birth.

Multiple first trimester abortions, and one or more second trimester abortions are risk factors.

Other medical risk factors include being underweight or overweight before pregnancy, short interval between pregnancies (less than six to nine months between birth and beginning of the subsequent pregnancy), and blood clotting disorders.

Smoking, excessive alcohol consumption, and drug misuse or abuses are risk factors.

Physical, sexual or emotional abuses are also risk factors attributable to the increased stress levels.

Other risk factors include long working hours, low income, little or no antenatal care, and lack of social support.

Get checked immediately!

Any pregnant woman should seek medical attention without delay if there are clinical features of premature labour.

These include uterine contractions occurring every 10 minutes or more often in an hour; leakage of watery liquor from the vagina; change or increase in the type (watery, mucus or bloody) of vaginal discharge; menstrual-like lower abdominal cramps; pelvic pressure, as if the foetus is pushing down; or constant low, dull backache.

The obstetrician or midwife will examine the patient to determine whether the mother is in premature labour.

Information about the frequency of contractions is provided by abdominal palpation and/or electronically with a cardiotocograph.

An examination with an instrument called a speculum may provide information about the dilatation of the cervix and/or leakage of amniotic fluid through the cervix.

If the membranes have not ruptured, a digital vaginal examination will be done to assess the dilatation of the cervix.

If the membranes have ruptured, it may not be done, as it will increase the chances of foetal infection.

The application of a nitrazine stick to the vaginal discharge may detect PPROM, although there may be false-positive results if the vaginal pH has been changed by urine.

A vaginal swab for culture is usually taken to facilitate appropriate antibiotic therapy if an infection develops later.

To stop or continue

When a diagnosis of premature labour is made, the primary consideration is to get the mother to a hospital that has the facilities for safe delivery of a premature baby, ie a NICU.

If the patient is at home, an ambulance with at least a midwife in attendance should be called for.

If the patient is in hospital, the paediatric team on call would be informed.

Premature labour may be stopped if diagnosed early, and there is no risk of infection, bleeding or other complications for the mother and foetus.

It may be allowed to continue if the labour is too advanced, or there are reasons that the foetus is better off being born, even if it is early. These reasons include infection, high blood pressure, bleeding or signs that the foetus has problems.

Corticosteroids are prescribed to help accelerate foetal lung maturity. They are most helpful if given between 24 to 34 weeks gestation, and 24 hours before the baby is born.

Medicines called tocolytics delay or inhibit uterine contractions.

They include beta2 agonists like ritodrine, salbutamol and terbutaline, which relaxes the uterine muscles; magnesium sulphate, which is believed to affect the function of calcium ions in uterine muscles; and non-steroidal anti-inflammatory drugs like indomethacin, which inhibit the production of prostaglandins that promote uterine contraction and thinning of the cervix.

Medicines like atosiban, which inhibit oxytocin, and nifedipine, which causes the blood vessels to dilate and acts directly on the uterine muscle, are also used. Both medicines have been reported to maintain tocolysis for a longer time, and have fewer side effects.

Tocolytics are rarely effective in reducing the contractions for more than 48 hours.

As such, its primary use is in delaying delivery for a sufficient time to allow corticosteroids to be given to the mother to reduce the risk of respiratory distress in the newborn.

This delay in delivery may also facilitate transfer to a hospital with a NICU.

Tocolytics are not given if the mother has conditions like an infection, heart or lung disease.

Antibiotics are usually prescribed with tocolytics to cover for infections, which may have been the cause of the premature labour.

The mode of premature delivery is influenced by the foetal presentation and gestation.

Most premature babies are delivered safely vaginally if the foetal presentation is head first, but a few will require CS. It is safer to deliver breech presentations below 32 weeks by CS.

Knowing helps in prevention

There are risk-scoring systems that are helpful in assessing the risk of premature labour.

Those identified may benefit from ultrasound measurements, which can detect a short cervix; fibronectin assessment (its presence in the cervical secretions at 22-23 weeks gestation is suggestive of increased risk); or salivary oestriol assessment, which does the same.

The risk of premature labour has been shown to be reduced with antibiotics prescribed to women at risk during the second trimester.

Tocolytics are prescribed to prevent premature labour from starting.

The measures that can be taken by a patient include smoking cessation; avoiding excessive alcohol consumption and/or drug misuse or abuse; seeking help if there is physical, sexual or emotional abuse; eating properly; getting plenty of rest; avoiding strenuous work and overexertion; and keeping antenatal clinic appointments.

It is important to be able to recognize the signs and symptoms of premature labour, and to know what to do.

There is evidence that the overall premature birth rate is reduced, the more women know about the risks and signs of premature labour.

Source: Dr Milton Lum

What happens when the baby’s buttocks or feet are facing downwards (instead of the head) when it comes to delivery time?

THE foetal presentation refers to how the foetus is situated in the uterus.

The foetal part that is nearest to the cervix is called the presenting part.

When the pregnancy gets to beyond 37 weeks, the foetal head (cephalic) is the presenting part in 97 out of 100 women, and the foetal buttocks (breech) or feet are the presenting part in three out of 100 women.

Although breech presentations are common earlier in pregnancy, the foetuses will usually turn into the cephalic position by themselves.

There are three types of breech presentation:

● Extended or frank breech, in which the foetal buttocks is nearest to the cervix with the thighs against the chest and feet further up near the side of the head, is commonest.

● Flexed breech, in which the buttocks are nearest to the cervix, with the thighs against the chest and the knees bent.

● Footling breech, in which the foetal foot or feet are below the buttocks.

Causes

There is no apparent reason for a breech presentation in many instances.

It may well be that the foetus does not turn spontaneously or is most comfortable presenting by the breech (or both).

However, there are factors that are responsible for a foetus presenting by the breech. They include labour prior to 37 weeks; too little or too much amniotic fluid in the sac surrounding the foetus; multiple pregnancy, usually twins; position of the placenta; length of the umbilical cord; and a uterus that has an irregular shape or fibroids, which are non-cancerous tumours of the uterine muscle.

Rarely, a breech presentation may be an indication that the foetus has problems.

In general, a breech presentation has no effect on a baby’s long-term health.

External cephalic version

If there is a breech presentation at 36 weeks, the obstetrician will discuss external cephalic version (ECV), which is a procedure used to turn a foetus from a breech or transverse presentation into a cephalic presentation prior to the commencement of labour.

When successful, ECV will make a vaginal birth possible.

The obstetrician will place both hands on the mother’s abdomen, one by the foetal head and the other by the buttocks, and then gently push the foetus into a cephalic presentation. (See illustrations on the right)

Prior to the ECV, a medication called a tocolytic, may be given to make the uterus relax and prevent uterine contractions from occurring.

There may or may not be discomfort during ECV, depending on the sensitivity of the abdomen, and how the obstetrician presses on the abdomen during the ECV.

Discomfort is more likely if the ECV causes the uterus to contract.

If the foetus appears to be in distress, as shown by a sudden drop in heart rate, the procedure is stopped.

The ECV is monitored throughout the process to ensure that the foetus is not harmed.

Ultrasound examination is initially carried out to confirm the foetal presentation, to locate the placenta, and to assess the amount of amniotic fluid.

It is also often used to check the foetal presentation during the procedure.

The foetal heart is checked before, possibly during, and certainly after ECV.

The methods of checking the foetal heart include the foetal stethoscope, ultrasound, or electronically.

The ECV is stopped if any foetal heart rate abnormalities occur.

The complications of ECV include commencement of labour; separation of the placenta from the uterus (abruption); rupture of the uterus; and damage to the umbilical cord.

Although complications are rare, they do occur. That is why ECV is carried out in a hospital that has facilities for immediate delivery by Caesarean section (CS) should complications occur.

ECV may be attempted at 36-37 weeks when there is only one foetus, which has not engaged in the maternal pelvis, and there is sufficient amniotic fluid.

The ECV is not done if the membranes have ruptured; the mother has a condition which does not permit her to be given tocolytics; a CS is needed, eg placenta praevia in which the placenta covers the cervix; in multiple pregnancy; or there are indications that the foetus may not be well or is known or suspected to have an abnormality.

The success rates of ECV have been reported to be about 60%.

Mode of delivery

The mode of delivery is either a vaginal breech delivery or CS, which is a surgical operation in which the foetus is delivered through an incision made in the mother’s abdomen.

The pros and cons of either mode of delivery have to be considered.

The management of a vaginal breech birth is similar to that of a cephalic presentation. The choices for pain relief are the same.

During the delivery, the mother will push the baby out of the birth canal to the point where the legs and lower body are delivered.

The baby will be supported by an assistant, and the legs held upwards for the rest of the body to be delivered.

The obstetrician may use some manoeuvres to deliver the shoulders, and/or a forceps to help deliver the baby’s head.

A vaginal breech delivery is more challenging as the head, which is the largest part of the foetus, is the last to be delivered, and this may pose problems in some instances.

The Royal College of Obstetricians and Gynaecologists of the United Kingdom supports vaginal breech delivery, provided that the obstetrician is trained and experienced in vaginal breech delivery, there are facilities for emergency CS, if it is necessary, and there are no risk factors present.

A vaginal breech delivery would not be considered if the foetus is a footling breech, large (estimated weight more than 3.8kg), small (estimated weight less than 2.0kg), or has a neck which is tilted backwards; or if the mother had a previous CS, small pelvis or raised blood pressure; or there is placenta praevia.

Attempts at a vaginal breech delivery may still result in a CS if labour is not proceeding satisfactorily, or there is indication of maternal or foetal complications. That is why vaginal breech delivery should only be carried out in a hospital where there are facilities for emergency CS.

The other mode of delivery for a breech presentation is a planned (elective) CS.

The risks of a CS are higher than that of a vaginal breech delivery.

The risks to the mother include infection of the wound and/or the uterus; excessive bleeding, which may require removal of the uterus (hysterectomy); damage to the bladder or the tube that connects the kidney to the bladder; blood clots (thrombosis) in the legs or pelvis (which may be life threatening if part of it dislodges and goes to the lungs – pulmonary embolism); and longer hospital stay.

There are also risks to the baby.

Accidental cuts on the baby’s skin when the uterus is incised occur in about two in 100 babies delivered by CS.

The most common risk is that of breathing difficulties, which occur in about 35 in 1,000 babies delivered by CS, compared to five in 1,000 babies delivered vaginally.

Their breathing may be more rapid immediately after birth and the first few days of life (transient tachypnoea). This usually resolves within two to three days.

The risk of the baby’s admission to the intensive care unit may also be increased.

There are also risks of anaesthesia to mother and baby.

The risks to mother and baby are usually increased in unplanned (emergency) CS due to problems in labour.

If a patient goes into labour before the planned CS of her choice, the obstetrician will make an assessment about the safety of doing an unplanned CS.

If birth is imminent, it may be safer to have a vaginal breech delivery.

If there is a twin pregnancy with the first foetus in a breech presentation, a planned CS will usually be recommended.

The position of the second twin is not as important as the foetal presentation can change after the birth of the first twin.

A breech presentation does not necessarily mean that a CS will be done. Many women have a vaginal breech delivery without any problems.

A discussion with the obstetrician will assist the patient in understanding the condition as well as the pros and cons of her management options.

The primary consideration must always be the health of both mother and baby.

Source: Dr Milton Lum

Kidney (renal) failure occurs when the kidneys are unable to perform their functions, leading to accumulation of toxic substances in the body, and consequent harm to health.

THE kidneys are two bean-shaped organs located on either side of the spine, in the space behind the abdominal cavity, which also contains the stomach, intestines, liver, spleen, and female genital organs.

The kidneys get its blood supply from the aorta through the renal arteries, which become progressively smaller in size. The smallest blood vessels, called arterioles, form groups of microscopic vessels called capillaries, each group of which is called a glomerulus. The blood leaves each glomerulus through an arteriole, which joins a small vein. The small veins join to form a large vein, which transports blood out of the kidney.

Each kidney has about a mil-lion nephrons, which are microscopic units that filter blood, producing urine in the process. Each nephron comprises a glomerulus and a tiny tubule that drains fluid from the glomerulus. The fluid becomes urine by the time it reaches a collecting duct.

When there is loss of kidney function, dialysis is required. In haemodialysis, the body’s waste products are removed by circulating blood through an artificial kidney machine.

There are numerous collecting ducts that lead to cup-like structures (calyces). Each kidney has many calyces, which all drain into a single large chamber-like structure (renal pelvis) from which the urine drains into another tube-like structure (ureter).

The two ureters from both kidneys join the bladder, from which the urine leaves the body through the urethra via the vulva in females and the penis in males.

The kidneys continuously produce urine, which is composed of excess water, salts, and waste products. Urine does not usually contain organisms or substances like glucose, proteins, ketones, blood etc.

The kidneys’ main function is to filter blood to get rid of waste products, toxins, and excess water and electrolytes from the body, whilst reabsorbing useful chemicals.

Many medicines are excreted by the kidneys. The kidneys help in the regulation of blood pressure and also produce hormones which help regulate the production of red blood cells, and the growth and maintenance of bones.

The kidneys enable a person to consume various food, medicines, fluids and substances without toxic by-products reaching harmful levels in the body.

The functions of both kidneys can be performed sufficiently by one kidney. That is why it is possible for a person to donate a kidney to another person.

Kidney (renal) failure occurs when the kidneys are unable to perform their functions, leading to accumulation of toxic substances in the body, and consequent harm to health.

Renal failure can be acute or chronic. The former occurs rapidly, and the latter, gradually over many years, during which the kidneys are destroyed slowly.

It is estimated that about 5% of hospitalised patients develop acute renal failure, with a higher incidence in patients in the intensive care unit.

Causes

The causes of acute renal failure are usually categorised into:

> Pre-renal: causes that affect the blood flow to the kidneys.

> Post-renal: causes that affect the flow of urine out of the kidneys.

> Renal: causes in the kidney itself that affect blood filtration and urine formation.

Pre-renal causes account for more than half of the causes of acute renal failure. The causes include dehydration, from vomiting, diarrhea, blood loss and diuretics; and reduced blood flow to the kidneys, from bleeding, severe injuries or burns, infections of the blood (septicaemia), heart attack or heart failure, blockage or narrowing of blood vessel supplying the kidneys and liver failure, which affects hormones regulating blood flow and pressure to the kidneys.

As the kidneys are not damaged by the pre-renal causes, the situation can be reversed with appropriate treatment. However, delayed or inadequate treatment can lead to permanent renal damage.

Post-renal causes are the least common causes of acute renal failure. The causes include obstruction of the ureters by stones or cancer of the urinary tract or adjacent structures; and obstruction at the bladder by stones, enlarged prostate in men, blood clots, bladder cancer and neurological conditions affecting the bladder’s ability to contract.

The situation is remedied by removal of the blockage, with the kidneys usually recovering its function within a week or two provided there is no infection. However, delayed or inadequate treatment can lead to permanent kidney damage.

Renal causes account for a quarter to half of all causes of acute renal failure. They may affect filtration, blood supply within the kidney, and the handling of salt and water. Although there are several renal conditions, the most common is acute tubular necrosis, a condition in which the tubules are damaged, leading to impairment of the kidney’s filtration function. The causes of this condition include shock, medicines, especially antibiotics, chemotherapeutic agents and poisons.

Glomerulonephritis is a condition in which the glomeruli are damaged by various causes, one of the most common being a streptococcal bacterial infection of the throat.

Acute interstitial nephritis is a condition in which there is inflammation of kidney tissue that deals with salt and water balance. The causes include medicines like antibiotics, painkillers and diuretics.

Clinical features

There may be no symptoms, especially in the early stages of acute renal failure or the symptoms may be non-specific. The symptoms include decreased passage of urine, swelling of the body, abdominal discomfort, lethargy, fatigue, poor concentration and confusion. Fits and coma may occur in severe acute renal failure.

The findings on physical examination are usually few.

A diagnosis is often made from laboratory investigations of the blood or urine. These tests may be done because the patient is generally unwell or hospitalised for another reason, or as part of screening tests.

The blood levels of urea and creatinine are raised when the causes are pre-renal. The serum electrolyte levels may be very high or low when there are filtration problems. A low haemoglobin count is present when there is severe renal failure or it is prolonged.

There may be inappropriate excretion of protein and other substances in the urine. The urine may be darkened by creatinine and other substances.

Microscopic examination of the urine may reveal blood, pus and casts, which are solid materials. The retention of urine in the bladder after passing urine is indicative of a post-renal cause, which is usually an enlarged prostate in men.

An ultrasound examination of the kidneys and bladder may reveal evidence of specific causes of the renal failure. Sometimes, a kidney biopsy may be done to obtain tissue samples of the kidneys for microscopic examination.

Management

The management of acute renal failure depends on the cause and its severity. The condition is usually managed by a kidney specialist (nephrologist) or a physician, if there is no nephrologist available.

The objectives of management are to identify and remove the cause of the failure, and to determine the extent to which the body is affected by the failure.

Dehydration will be corrected with intravenous fluids. If the body’s excess fluids are not adequately removed by the kidneys, fluid intake should be limited. If the blood flow to the kidneys is reduced, measures will be taken to improve cardiac function and increase blood pressure. Electrolyte abnormalities will be corrected so that other bodily functions will not be impaired.

A review of the patient’s medicines and food intake will be made. The compounds that are harmful to the kidneys will be removed or their dosages reduced.

If there is no response to the management measures and renal function does not return to normal, renal dialysis will be carried out. There are two types of dialysis, i.e. through the blood vessels (haemodialysis) or through the abdominal cavity (peritoneal dialysis). The body’s waste products are removed by circulating the blood through an artificial kidney machine in the former, and through a catheter inserted into the abdominal cavity in the latter.

The majority of patients do not require dialysis if the cause is identified and removed or treated. This is particularly so if the cause is not due to kidney damage, when there is usually restoration of normal renal function.

However, there are instances where there may be residual kidney damage resulting in only partial restoration of function. Although such patients may not need dialysis, many have to take medicines to handle the loss of function.

Prevention

Several measures can be taken to prevent acute renal failure. Adequate fluid consumption will ensure proper functioning of the kidneys. The avoidance of medicines that can damage the kidneys would be very helpful. This is one of the reasons why doctors hold the view that self-medication should be done only with the advice of the doctor.

When one is unsure or does not know the side-effects of medicines, it is prudent to seek advice from the doctor or the pharmacist.

Annual medical examinations will provide information about the health status of the kidneys and urinary tract.

Patients at increased risk of chronic renal disease should be aware of the need for early medical attention, particularly when they have urinary symptoms or notice changes in the urine. They also have need for more frequent medical check-ups and tests of renal function.

Source: Dr Milton Lum

Bedwetting in children

Most children can control voiding by the age of five years. However, incontinence can occur in about 1% of those aged 18 years.

THE kidneys produce urine, which passes through the ureters to enter the bladder, a hollow and distensible organ that sits on the pelvic floor. The stored urine exits the body through the urethra, which is a tubular structure. This act (voiding) involves muscles, nerves, the spinal cord and the brain.

The bladder has two types of muscles. The detrusor muscle stores urine and contracts when emptying the bladder. The bladder sphincter is a circular group of muscles found at the bottom of the bladder. It automatically contracts to retain urine in the bladder and relaxes when the detrusor muscle contracts (when the urine gets into the urethra).

When the pelvic floor muscles contract, urine is held back in the bladder.

The newborn’s bladder fills up to a certain set level at which the bladder muscle contracts automatically, leading to voiding. As the newborn grows, his or her nervous system matures. The brain starts receiving messages from the filling bladder through the spinal cord and also sends messages to the bladder.

Eventually, the child is able to stop the bladder from voiding automatically until the child decides when and where to void.

When the control mechanisms are immature or fails, it results in bedwetting (incontinence). Most children are able to control voiding by the age of five years. However, incontinence can occur in about 1% of those aged 18 years. Incontinence is twice as common in males as compared to females.

There are certain medical terms used to describe incontinence in children:

> Primary enuresis is incontinence in someone who has never been dry for at least six months

> Secondary enuresis is incontinence that begins after at least six months of dryness

> Nocturnal enuresis is incontinence which occurs during sleep. It is also called night time incontinence

> Diurnal enuresis is incontinence which occurs when awake. It is also called daytime incontinence

There are several causes of bedwetting in children and they vary from the simple to the complex.

Causes

Nocturnal enuresis is more common than diurnal enuresis after the age of five years. The causes of nocturnal enuresis are not well clarified yet. Most cases result from a variety of causes that include slower physical development, an increased production of urine at night, a lack of ability to recognise bladder filling when asleep, and, occasionally, anxiety.

Nocturnal enuresis between the ages of five and 10 years due to a smaller bladder capacity usually disappears gradually as the bladder capacity increases.

The body produces a hormone called antidiuretic hormone (ADH) which reduces the production of urine. As less ADH is produced at night, the need to void is less. Sometimes the body does not produce sufficient ADH at night, leading to the production of more urine. If a child does not sense the increased volume of urine in the bladder and awakens to void, bed wetting will result.

Anxiety has been suggested as a cause of bedwetting in children between two and four years of age when they have yet to achieve total control of their bladders. Anxiety after the age of four years can also lead to nocturnal enuresis after the child has been dry for six months or more. The anxiety-causing events include angry parents or relatives, birth of a sibling, and unfamiliar social situations.

Incontinence itself can cause anxiety. Diurnal enuresis can cause anxiety that leads to nocturnal enuresis.

A strong family history of bedwetting is suggestive of genetic causes. Studies have reported that a child has an 80% chance of bedwetting if both parents had been bed wetters.

There is a small group of children who have physical abnormalities in their urinary tract which lead to incontinence, e.g. a blocked bladder or urethra, and nerve damage associated with spina bifida, which is a birth defect of the spinal cord.

Diurnal enuresis is less common than nocturnal enuresis and usually disappears earlier than nocturnal enuresis.

An overactive bladder is one of the causes of diurnal enuresis. When the detrusor muscle of the bladder contracts strongly, the bladder sphincter may be unable to prevent voiding. This occurs frequently when there is a urinary tract infection (UTI), which is more common in girls because of their short urethras.

Many children who have diurnal enuresis have abnormal habits, the most common being infrequent voiding. They ignore the feeling of a full bladder and do not void for long periods for various reasons, e.g. not wanting to use the toilets at school. As the bladder is overfilled, the urine leaks. Such children are prone to UTIs, which in turn leads to an overactive bladder.

The causes of nocturnal enuresis may interact with infrequent voiding to lead to diurnal enuresis. These causes include small bladder capacity, anxiety, and physical abnormalities of the urinary tract. Pressure from a distended lower bowel, when a child has constipation, and caffeine-containing foods or drinks, that increase urine output, are other contributory causes.

Management

There are various management modalities available. They include no treatment, bladder training, medicines, dietary modification, and moisture alarms.

Most cases of bedwetting in children resolve spontaneously without any treatment as the child grows up. It has been estimated that the incidence of bed wetting reduces by 15% annually after the age of five years.

The body’s changes with the passage of time include an increase in bladder capacity, resolution of an overactive bladder, the normal production of ADH, the resolution of anxiety provoking events, and the child learning to respond to the signals that it is time to void.

Bladder training involves exercises that help to strengthen and co-ordinate the bladder’s muscles. The child learns to anticipate the need to void and to control oneself when there is no toilet nearby.

The methods used for nocturnal enuresis include determining bladder capacity, drinking less before bed time, and having a routine for waking.

The methods used for diurnal enuresis include voiding according to a schedule, avoiding caffeine containing foods or drinks, and relaxing the muscles. There is, however, no guarantee of success with these bladder training methods.

There are medicines available to treat bed wetting. ADH levels can be increased with desmopressin, and an overactive bladder controlled with anticholinergics.

The medicine, imipramine, which acts on the brain and bladder, is used for short term treatment of nocturnal enuresis.

Moisture alarms awaken a person when voiding starts. The device has a water-sensitive pad that is placed in the pajamas and is connected to a battery-driven control. An alarm goes off when moisture is detected on the pad. The child has to wake up when the alarm goes off and go to the washroom to void.

The use of such alarms may require another person to sleep in the same room as the child to awaken him or her.

Bedwetting is common in young children. It resolves spontaneously in most instances. The management modalities include no treatment, bladder training, medicines, dietary modification, and moisture alarms. Anyone whose child has bedwetting would benefit from a reassuring discussion with the doctor.

Source: Dr Milton Lum

Irrespective of whether the amount of urine leaked is small or large, incontinence can be distressing and embarrassing.

THE kidneys produce urine which passes through the ureters to enter the bladder, a hollow and distensible organ that sits on the pelvic floor that has a hammock-like structure comprising muscles and connective tissue. The pelvic floor supports organs like the bladder, intestines, and the uterus in females and has a narrow gap through which the urethra, rectum, anus, and vagina traverse.

The urine exits the bladder through the urethra. This occurs when both the bladder’s internal and external sphincters are opened. The control of the former is involuntary and the latter, which is a circular muscle around the urethra, voluntary. Although there is individual variation in bladder capacity, it is generally accepted that the capacity in the adult is about 500 ml. The desire to urinate occurs when the bladder volume is about 300 to 350 ml. As the bladder continues to fill, the desire to urinate increases and becomes more difficult to ignore.

The bladder can store a large volume of urine without much increase in internal pressure. When there is an increase in intra-abdominal pressure, e.g. coughing, sneezing, laughing, heavy lifting, exercising, or changing position, this is usually transmitted equally to the pelvic floor and organs, including the bladder.

However, when there is weakness of the pelvic floor muscles and/or external sphincter, or malfunction of the external sphincter, an involuntary leakage of urine can occur when the intra-abdominal pressure is increased. This is because the external sphincter cannot stay closed to prevent urine flow from the bladder, and this is called stress urinary incontinence (SUI).

SUI has to be distinguished from urge incontinence, which is due to overactive bladder muscles that leads to a strong urge to urinate even when there is little urine in the bladder.

There may be situations in which there is both SUI and urge incontinence. There are also other causes of incontinence like prostate problems and nerve damage.

In short, urinary incontinence is tantamount to loss of bladder control. The symptoms can range from mild leaks to uncontrollable ones. It can happen at any age but is more common with increasing age.

Irrespective of whether the amount of urine leaked is small or large, incontinence can be distressing and embarrassing.

Risk factors

There are several factors that increase the risk of SUI – which is the most common type of urinary incontinence in women.

Pregnancy and childbirth increase the risk of SUI. The increasing weight of the developing baby in pregnancy exerts increased stress on the pelvic floor. Furthermore, the hormone, relaxin, which is produced in pregnancy, softens the pelvic floor muscles in preparation for childbirth. These changes result in SUI in about half of all pregnant women.

During vaginal delivery, the pelvic floor can get stretched and bruised. This can have subsequent effects on the functioning of the pelvic nerves and muscles. A Danish study of more than 2,000 women reported that the risk of developing urinary incontinence was increased three times in women who had a perineal tear or episiotomy.

SUI which develops during pregnancy or after childbirth usually improves with time. However, it may recur and treatment may be required.

After the cessation of periods (menopause), oestrogen levels are decreased considerably. As the pelvic floor is oestrogen dependent, the muscle pressure around the urethra is weaker after menopause. This, combined with the decreased elasticity of the urethra with consequent inability to close completely, increase the likelihood of SUI.

Postmenopausal women are also more likely to be overweight and have had a hysterectomy, both of which increase the risk of SUI. Hysterectomy is an operation in which the uterus is removed and can lead to damage of the pelvic floor.

There is more pressure on the abdomen in the overweight, with consequent increase in pressure on the pelvic floor. A British study reported that overweight women were twice as likely to have SUI when compared to someone of normal weight.

Chronic cough, which is more common in smokers, increases the pressure on the pelvic floor, thereby weakening its muscles and increasing the risk of SUI.

Some medicines can affect the pelvic floor, e.g. some high blood pressure medicines, antidepressants, sedatives, and muscle relaxants.

The bladder’s sphincter muscle can be damaged by pelvic fracture, bladder neck surgery or radical prostatectomy in men. And there are some rare individuals who have an inherited weakness of the pelvic floor muscles.

Clinical features

Patients with SUI complain of an involuntary loss of urine when coughing, sneezing, laughing, heavy lifting, exercising, changing position, or during sexual intercourse.

The physical examination will involve a general, abdominal and rectal examination, including a pelvic examination in women and genital examination in men.

The findings may include bulging of the bladder or urethra into the vaginal space (cystocoele or urethrocoele) and/or uterine prolapse. SUI can be tested by getting the patient to cough, strain, or stand with a full bladder.

The usual investigations include an abdominal and/or pelvic ultrasound and urinalysis and/or culture to exclude urinary tract infection.

Other investigations include checking the residual urine in the bladder after voiding and a pad test which involves weighing a pre-weighed sanitary pad after exercise to determine the amount of urine loss.

Other investigations that may be done include x-rays of the urinary tract after intravenous injection of dye, i.e. intravenous pyelogram (IVP), urodynamic studies, inspecting the inside of the bladder with a telescope-like instrument (cystoscopy), and rarely, electromyography to check on the muscle activity.

Patients may also be asked to keep a record of the times of voiding and leaking of urine.

Management

There are four management modalities available, i.e. lifestyle changes, pelvic floor exercises, medicines, and surgery. The modalities may be used alone or in combination The choice(s) are influenced by the severity of the problem and the extent to which it interferes with daily life.

Lifestyle changes include smoking cessation; weight reduction, if overweight; good diabetic control; voiding more often to reduce the amount of urine that leaks; ensuring regular bowel movements to avoid constipation, which can worsen SUI; avoiding excessive fluid intake, caffeine and alcohol (which can stimulate the bladder), and food and drinks that may irritate the bladder, e.g. carbonated drinks; and avoiding heavy lifting, running, or jumping.

Pelvic floor muscle training (PFMT), often called Kegel exercise, strengthens the pelvic floor muscles, particularly the urethral sphincter. It involves alternate contraction and relaxation of the pelvic floor muscles. The challenge for many women is to identify the muscles. This can be done by inserting a finger into the vagina and squeezing the surrounding muscles. The vagina would tighten and the pelvic floor moves upward. Upon relaxation of the muscles, the pelvic floor would return to the starting position.

Men can also do PFMT. The pelvic floor muscles can be identified during voiding and attempting to stop it completely once urine starts to flow. The muscles that tighten up are the pelvic floor muscles.

PFMT can be done at any time without other persons noticing it. One should try and do PFMT as advised by the doctor. If done regularly, an improvement (less frequent leakage) will be noticeable within four to 12 weeks.

A review of trials published in the Cochrane database found that “pelvic floor muscle training (muscle-clenching exercises) helps women with all types of incontinence, although women with stress incontinence who exercise for three months or more benefit most.”

The review reported “support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress, urge, or mixed, urinary incontinence.”

Different types of medicines may be prescribed in SUI. They include antibiotics for urinary tract infections and topical oestrogens in post-menopausal women. The latter improves urinary frequency and urgency as well as the tone and blood supply of the urethral sphincter muscles.

However, whether oestrogens improve SUI is controversial.

Surgery is recommended for SUI in selected patients, usually after PFMT has been attempted. Various surgical techniques are available. They include anterior vaginal repair; colposuspension; collagen injections; tension free vaginal tape; and vaginal sling procedures.

The gynaecologist or the urologist, who are the specialists who perform such procedures, will discuss with the patient the pros and cons of the different techniques.

There are risks of complications in surgery and they include surgical site infections, urinary tract infections, vaginal infections, erosion of the surgically placed materials, and painful sexual intercourse. Although uncommon, complications can and do occur.

Failures of treatment are more common in patients who have conditions that hamper healing or surgery, have other problems of the genitourinary tract, or whose surgery failed previously.

Performing PFMT may help prevent symptoms and doing it during and after pregnancy can decrease the risk of developing SUI after childbirth.

Source: Dr Milton Lum